Disease clearance in ulcerative colitis: Setting the therapeutic goals for future in the treatment of ulcerative colitis

Ulcerative colitis, one of the phenotypic patterns of inflammatory bowel disease, should be considered a progressive disease with an increased risk of complications if intestinal inflammation is not adequately controlled. The advent of new lines of treatment for this condition has changed and expanded the therapeutic goals to modify its natural history and evolution. The concept of "disease clearance" in ulcerative colitis aims to achieve clinical and biological remission as well as mucosal healing (endoscopic, histological, and in future molecular) in these patients. This review provides the available data on each of the goals of disease clearance in ulcerative colitis to be considered for application in clinical practice in the coming years.

More Than Just an Entertainment Show: Identification of Medical Clowns' Communication Skills and Therapeutic Goals

Medical clowns (MCs) are trained professionals who aim to change the hospital environment through humor. Previous studies focused on their positive impact and began identifying their various skills in specific situations. When placed in pediatrics, MCs face various challenges, including approaching frustrated adolescents who are unwilling to cooperate with their care, dealing with their anxious parents, and communicating in a team in the presence of other health professionals. Research that systematically describes MCs' skills and therapeutic goals in meeting these challenges is limited. This article describes a qualitative, immersion/crystallization study, triangulating between 26 video-recorded simulations and 12 in-depth-semi-structured interviews with MCs. Through an iterative consensus-building process we identified 40 different skills, not limited to humor and entertainment. Four main therapeutic goals emerged: building a relationship, dealing with emotions, enhancing a sense of control, caring, and encouragement, and motivating treatment adherence. Mapping MCs' skills and goals enhances the understanding of MCs' role and actions to illustrate their unique caring practices. This clarification may help other healthcare professionals to recognize their practices and the benefits in involving them in care. Furthermore, other health professionals may apply some of the identified skills when faced with these challenges themselves.

Real-world clinical management of individuals with Rett syndrome: a physician survey

BACKGROUND

Rett syndrome (RTT) is a severe neurodevelopmental disorder. Management strategies are heterogeneous with no clear definition of success. This study describes physician decision-making regarding diagnosis, therapeutic goals, and management strategies to better understand RTT clinical management in the US.

METHODS

This study was conducted among practicing physicians, specifically neurologists and pediatricians in the US with experience treating ≥2 individuals with RTT, including ≥1 individuals within the past two years. In-depth interviews with five physicians informed survey development. A cross-sectional survey was then conducted among 100 physicians.

RESULTS

Neurologists had treated more individuals with RTT (median: 12 vs. 5, p < 0.001) than pediatricians throughout their career and were more likely to report being "very comfortable" managing RTT (31 vs. 4%, p < 0.001). Among physicians with experience diagnosing RTT (93%), most evaluated symptoms (91%) or used genetic testing (86%) for RTT diagnoses; neurologists used the 2010 consensus diagnostic criteria more than pediatricians (54 vs. 29%; p = 0.012). Improving the quality of life (QOL) of individuals with RTT was the most important therapeutic goal among physicians, followed by improving caregivers' QOL. Most physicians used clinical practice guidelines to monitor the progress of individuals with RTT, although neurologists relied more on clinical scales than pediatricians. Among all physicians, the most commonly treated symptoms included behavioral issues, epilepsy/seizures, and feeding issues. Management strategies varied by symptom, with referral to appropriate specialists being common across symptoms. A large proportion of physicians (37%) identified the lack of novel therapies and reliance on symptom-specific management as an unmet need.

CONCLUSION

Although most physicians had experience and were comfortable diagnosing and treating individuals with RTT, better education and support among pediatricians is warranted. Additionally, novel treatments that target multiple symptoms associated with RTT could reduce the burden and improve the QOL of individuals with RTT and their caregivers.

Knowledge of the Therapeutic Goals of Diabetes Care among Patients with Type 2 Diabetes at a Tertiary Hospital in Ethiopia

Background

A comprehensive cardiovascular risk control reduces diabetes-associated complications but achieving the triplet goals (blood glucose, blood pressure (BP), and low-density lipoprotein (LDL-C)) remains a clinical challenge. Patients' knowledge of these diabetes therapeutic goals has been shown to improve glycemic control. However, this is not well studied in Ethiopia.

Methods

A cross-sectional study was conducted from March to June 2020 in Tikur Anbessa Specialized Hospital among randomly selected 419 patients with type 2 diabetes. Data was collected using a pretested, structured questionnaire. A multivariable binary logistic regression was fitted to identify determinants of knowledge.

Results

The mean age (±SD) of study participants was 57.4 (±10.8) years and the median duration (IQR) of diabetes was 12 (7, 20) years. A quarter of them achieved fasting glycemic control, a fifth of them attained the A1c goal and only 3% achieved the triple targets. Patients who reported knowing their target goals for BP, fasting blood sugar (FBS), A1C, and LDL-C were 79.5, 77.3, 11.7, and 7.2% respectively. The factors associated with knowledge of the therapeutic goals were longer diabetes duration, increased household income, age, being divorced as compared to married, having no formal education, and primary education.

Conclusion

The majority of participants knew their BP and FBS targets while only a minority understood their A1c and LDL-C targets. It highlighted the need for the provision of patient-centered diabetes education to improve knowledge of the therapeutic targets.

Do NSAIDs Take Us Away From Treatment Goals in Axial Spondyloarthritis: A Story About Dysbiosis or Just a Matter of Bias?

Non-steroidal anti-inflammatory drugs (NSAIDs) remain the mainstay of treatment for spondyloarthritides (SpA), a group of entities with common clinical and pathophysiological aspects, but also with differential features. Although NSAIDs provide significant symptomatic relief, especially for joint pain and morning stiffness, their role in achieving and maintaining the treatment goals advocated by the treat to target strategy in SpA is not entirely clear. These agents can induce changes in the composition of the intestinal microbiota, also favoring an alteration of the barrier function in the gut epithelium. All of this, favored by a pre-disposing genetic background, could activate a specific type of aberrant immune response in the gut lamina propria, also known as type-3 immunity. This article offers a perspective on how NSAIDs, despite their undeniable value in the short-term SpA treatment, could hinder the achievement of medium and long-term treatment goals by compromising the barrier function of the gut mucosa and potentially altering the composition of the gut microbiota.

Combination therapy in the treatment of hypertension

Hypertension is a major preventable risk factor for atherosclerosis and ischemic heart disease. Although modern and effective antihypertensive drugs are available, most patients remain with a suboptimal blood pressure control. Most hypertensive patients will need a combination of antihypertensive agents to achieve the therapeutic goals – recent guidelines recommend initiating treatment with two drugs in those patients with a systolic blood pressure >20 mmHg and/or a diastolic blood pressure >10 mmHg above the goals, and in those patients with high cardiovascular risk. In addition, approximately 25% of patients will require three antihypertensive agents to achieve the therapeutic targets. In this review, we analyse the latest information available regarding the treatment of hypertension with combination therapy.

Imiglucerase in the management of Gaucher disease type 1: an evidence-based review of its place in therapy

Introduction

Gaucher disease is the first lysosomal disease to benefit from enzyme replacement therapy, thus serving as model for numerous other lysosomal diseases. Alglucerase was the first glucocerebrosidase purified from placental extracts, and this was then replaced by imiglucerase – a Chinese hamster ovary cell-derived glucocerebrosidase.

Aim

The aim was to review the evidence underlying the use of imiglucerase in Gaucher disease type 1

Evidence review

Data from clinical trials and Gaucher Registries were analyzed.

Conclusion

Imiglucerase has been prescribed and found to have an excellent efficacy and safety profile. We report herein the evidence-based data published for 26 years justifying the use of imiglucerase.

New drugs and patient-centred end-points in old age: setting the wheels in motion

Older patients with various degrees of frailty and disability, a key population target of pharmacological interventions in acute and chronic disease states, are virtually neglected in pre-marketing studies assessing the efficacy and safety of investigational drugs. Moreover, aggressively pursuing established therapeutic targets in old age, e.g. blood pressure, serum glucose or cholesterol concentrations, is not necessarily associated with the beneficial effects, and the acceptable safety, reported in younger patient cohorts. Measures of self-reported health and functional status might represent additional, more meaningful, therapeutic end-points in the older population, particularly in patients with significant frailty and relatively short life expectancy, e.g. in the presence of cancer and/or neurodegenerative disease conditions. Strategies enhancing early knowledge about key pharmacological characteristics of investigational drugs targeting older adults are discussed, together with the rationale for incorporating non-traditional, patient-centred, end-points in this ever-increasing group.

The attenuated/late onset lysosomal storage disorders: Therapeutic goals and indications for enzyme replacement treatment in Gaucher and Fabry disease

Enzyme replacement therapies have been developed and authorized for commercial use for six different lysosomal storage disorders. For Gaucher disease, Fabry disease and mucopolysaccharidosis type 1, disease-specific treatments have been available for more than a decade. Although long term follow-up data are still sparse, therapeutic goals for patients with Gaucher disease and Fabry disease have been formulated and published for both adults and children. Without adaptation or modification, these goals are often applied in clinical research and in routine patient care across the entire phenotypic spectrum of disease, although in practice, patients commonly manifest high variability in clinical presentation and course of the illness. In this context, establishing goals for the follow-up and treatment of late onset/attenuated phenotypes is particularly challenging. In this chapter, we review current therapeutic goals for Gaucher disease and Fabry disease and discuss approaches for those with attenuated disease manifestations.

Toward quality care in ADHD: defining the goals of treatment

OBJECTIVE

Therapeutic goals for chronic mental disorders like major depressive disorder (MDD) and schizophrenia have evolved in parallel with the growing medical knowledge about the course and treatment of these disorders. Although the knowledge base regarding the clinical course of ADHD, a chronic psychiatric disorder, has evolved beyond symptomatic improvement and short-term treatment response, long-term goals, such as functional remission, have not yet been clearly defined.

METHOD

A PubMed literature search was conducted to investigate the therapeutic goals of pharmacologic treatment referenced in the published literature from January 1998 through February 2010 using the following commonly used ADHD treatments as keywords: amphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine, and clonidine. This search was then combined with an additional search that included the following outcome keywords: remission, relapse, remit, response, normal, normalization, recovery, and effectiveness.

RESULTS

Our search identified 102 publications. The majority (88.2% [90/102]) of these contained predefined criteria for treatment response. Predefined criteria for normalization and remission and/or relapse were presented in 4.9% (5/102), 12.7% (13/102), and 3.9% (4/102) of publications, respectively. There was a lack of consistency between the instruments used to measure outcomes as well as the criteria used to define treatment response, normalization, and remission as well as relapse.

CONCLUSION

The therapeutic goals in treating ADHD should address optimal treatment outcomes that go beyond modest reductions of ADHD symptoms to include syndromatic, symptomatic, and functional remission. Future work should focus on reliable and valid tools to measure these outcomes in the clinical trial setting.