Upadacitinib Reduces Crohn's Disease Symptoms Within the First Week of Induction Therapy

BACKGROUND & AIMS

Upadacitinib (UPA), an oral Janus kinase inhibitor, is approved to treat moderately to severely active Crohn's disease (CD). Because symptomatic response is an important initial treatment goal for patients, we evaluated the rapidity of symptomatic improvement in patients with CD receiving UPA 45 mg once daily (UPA45) induction therapy.

METHODS

This post hoc analysis included pooled data from 2 phase 3, multicenter, double-blind, 12-week induction trials (U-EXCEL and U-EXCEED) and 1 maintenance trial (U-ENDURE). Daily diary data for the first 15 days of UPA45 or placebo (PBO) treatment were used to analyze improvement in very soft/liquid stool frequency (SF) and abdominal pain score (APS). Clinical outcomes were evaluated at every study visit.

RESULTS

Overall, 1021 patients (n = 674 UPA45; n = 347 PBO) were analyzed. UPA45 demonstrated greater efficacy vs PBO for SF <3 and APS ≤1, providing rapid relief by day 5 or 6, regardless of prior biologic exposure. Mean changes in SF and APS were greater with UPA45 beginning at week 2 (-2.0 and -0.5, respectively; P < .001) and were maintained through week 12 (-3.0 and -1.0, respectively; P < .001) vs PBO. The first achievement of daily SF/APS clinical remission occurred earlier with UPA45 (median, 13 d) vs PBO (median, 32 d), and patients treated with UPA45 showed improved rates of SF/APS clinical remission (21.1% UPA45 vs 8.9% PBO) and clinical response (58.8% UPA45 vs 37.9% PBO) starting at week 2 (both P ≤ .01).

CONCLUSIONS

UPA45 provided rapid relief of clinical symptoms within the first week of treatment in patients with CD.

CLINICALTRIALS

gov numbers: NCT03345849, NCT03345836, and NCT03345823.

Upadacitinib Achieves Clinical and Endoscopic Outcomes in Crohn's Disease Regardless of Prior Biologic Exposure

BACKGROUND & AIMS

Upadacitinib, an oral Janus kinase inhibitor, achieved significantly higher rates of clinical remission and endoscopic response vs placebo during induction (U-EXCEL [NCT03345849], U-EXCEED [NCT03345836]) and maintenance (U-ENDURE [NCT03345823]) treatment in patients with moderate-to-severe Crohn's disease. Prior biologic failure is often associated with reduced responses to subsequent therapies. This post hoc analysis assessed upadacitinib efficacy by prior biologic failure status.

METHODS

Patients were randomized to placebo or upadacitinib 45 mg (UPA45) for 12 weeks (induction). UPA45 clinical responders were enrolled in U-ENDURE and rerandomized to placebo, upadacitinib 15 mg, or upadacitinib 30 mg (UPA30) for 52 weeks. Assessments were by prior biologic failure.

RESULTS

Of 1021 patients, 733 (71.8%) had prior biologic failure. Across outcomes and subgroups, upadacitinib-treated patients achieved higher rates vs placebo. During induction, upadacitinib had higher rates vs placebo for clinical remission based on stool frequency/abdominal pain score (without failure: 54.0% vs 28.3%; with failure: 42.2% vs 14.1%) and endoscopic response (without failure: 52.0% vs 16.2%; with failure: 35.7% vs 5.3%). In maintenance, the greatest treatment effect (upadacitinib vs placebo) was among patients with prior biologic failure treated with UPA30 (clinical remission without failure: 58.5% vs 32.7%; with failure: 42.5% vs 8.7%; endoscopic response without failure: 43.9% vs 17.9%; with failure: 38.9% vs 4.0%). Patients without vs with prior biologic failure had fewer adverse events.

CONCLUSIONS

Upadacitinib led to higher absolutes rates of clinical and endoscopic outcomes in patients without vs with prior biologic failure. Patients treated with upadacitinib achieved greater rates of clinical and endoscopic improvements vs placebo, regardless of prior biologic exposure.

CLINICALTRIALS

gov: NCT03345849, NCT03345836, NCT03345823.

Factors leading to satisfaction with counseling for Labor after Cesarean among Latina women in the United States

BACKGROUND

Cesarean birth, especially repeat cesarean, is associated with significantly higher morbidity than vaginal birth. Appropriately counseling women who are candidates for labor after cesarean (LAC) has the potential to confer significant health benefits for women. Little guidance exists about optimal counseling techniques, especially for Latina women. The aim of this study was to evaluate satisfaction among Latinas about how LAC counseling is performed, specifically as it relates to shared decision making.

METHODS

We conducted a qualitative study of pregnant women at several clinics in a Federally Qualified Health Center system in Utah. We interviewed eleven Latina women about satisfaction with recent LAC counseling with a specific aim of obtaining rich, personal narratives rather than reaching data saturation. A codebook representing the most common themes was developed.

RESULTS

Three major themes emerged related to LAC counseling including influences on satisfaction, influences on the birth decision process, and preferences surrounding method and timing of counseling. Women experienced greater satisfaction from providers who used jargon-free communication, were perceived as trustworthy, cared about her experiences, and empowered her to make an informed decision. Women's decisions were influenced by prior birth experiences, desire for a safe delivery and easy recovery, and future family planning.

CONCLUSIONS

Understanding the aspects of LAC counseling that are most meaningful for Latina women can promote effective communication between patient and provider and improve patient satisfaction. Globally, our findings highlight the importance of evaluating the experiences and preferences of minority groups; majority populations cannot be assumed to speak for minority populations.

Restoring the Human in Humanistic Psychology

Positivistic psychologies marginalize transcendent human values by reducing them to by-products of naturalistic mechanisms. One result is a depersonalized and depersonalizing psychology. Humanistic psychology reasserted transcendental values and made them the central motives of its theory of human behavior. However, humanistic psychology shared the core secularizing assumptions of positivism in locating transcending values as “inner” impulses and instincts rather than as experiences of real participation in the transcendent order toward which they aimed. Lacking an understanding of a real reference point outside the self, humanistic psychology tended to divinize the self and its higher values, minimizing as it did so the infrahuman and societal conditions of the self. To contribute to a truly human psychology, the radical critique of positivist reductionism that began with humanistic psychology can only move forward by taking seriously the realities indicated by the human experiences of participation in embodied, social, and transcendent being.

Screening, diagnosis, and management of gestational diabetes mellitus

Gestational diabetes mellitus (GDM) affects approximately 6% of pregnancies in the United States, and it is increasing in prevalence. Pregnant women without known diabetes mellitus should be screened for GDM after 24 weeks of gestation. Treatment of GDM results in a statistically significant decrease in the incidence of preeclampsia, shoulder dystocia, and macrosomia. Initial management includes glucose monitoring and lifestyle modifications. If glucose levels remain above target values, pharmacologic therapy with metformin, glyburide, or insulin should begin. Antenatal testing is customary for women requiring medications. Induction of labor should not occur before 39 weeks in women with GDM, unless glycemic control is poor or another indication for delivery is present. Unless otherwise indicated, scheduled cesarean delivery should be considered only in women with an estimated fetal weight greater than 4,500 g. Women with a history of GDM are at high risk of subsequently developing diabetes. These patients should be screened six to 12 weeks postpartum for persistently abnormal glucose metabolism, and should undergo screening for diabetes every three years thereafter.

Determinants of Endurance Exercise Capacity in the Heat in Prepubertal Boys

The goal of this study was to identify factors which limit exercise endurance in hot ambient conditions in prepubertal boys. Eight healthy non-acclimatized, highly physically active prepubertal boys performed steady load cycling at approximately 65 % peak VO (2) to exhaustion in both cool (19.6 +/- 0.6 degrees C, 66.4 +/- 11.0 % relative humidity) and hot (31.0 +/- 0.3 degrees C, 56.9 +/- 2.0 % relative humidity) environmental conditions. Cardiac output, oxygen uptake, rectal temperature (T (re)), rating of perceived exertion (RPE), blood pressure, and calculated arterial venous oxygen difference were obtained serially in each testing session, and percent dehydration was calculated from body weight loss. Endurance time was significantly shorter in the hot condition (29.30 +/- 6.19 minutes versus 41.38 +/- 6.30 minutes in the cool room). No significant differences in circulatory markers or hydration status were observed either during testing or between cycling thermal conditions. Rate of rise of T (re) was greater during exercise in the heat, but no significant difference in T (re) between conditions was observed at exhaustion. Mean values of RPE were consistently greater during exercise in the heat, but these differences did not reach statistical significance. These findings support the concept that rises in core temperature and/or brain perception (RPE) rather than circulatory insufficiency may be the critical factors defining limits to exercise in the heat.

A prospective assessment of mortality in chronic spinal cord injury

STUDY DESIGN

Prospective mortality study.

OBJECTIVE

To assess the relationship between comorbid medical conditions and other health-related factors to mortality in chronic spinal cord injury (SCI).

SETTING

Boston, MA, USA.

METHODS

Between 1994 and 2000, 361 males >/=1 year after injury completed a respiratory health questionnaire and underwent pulmonary function testing. Cause-specific mortality was assessed over a median of 55.6 months (range 0.33-74.4 months) through 12/31/2000 using the National Death Index.

RESULTS

At entry, mean (+/-SD) age was 50.6+/-15.0 years (range 23-87) and years since injury was 17.5+/-12.8 years (range 1.0-56.5). Mortality was elevated (observed/expected deaths=37/25.1; SMR=1.47; 95% CI=1.04-2.03) compared to US rates. Risk factors for death were diabetes (RR=2.62; 95% CI=1.19-5.77), heart disease (RR=3.66; 95% CI=1.77-7.78), reduced pulmonary function, and smoking. The most common underlying and contributing causes of death were diseases of the circulatory system (ICD-9 390-459) in 40%, and of the respiratory system in 24% (ICD-9 460-519).

CONCLUSIONS

These results suggest that much of the excess mortality in chronic SCI is related to potentially treatable factors. Recognition and treatment of cardiovascular disease, diabetes, and lung disease, together with smoking cessation may substantially reduce mortality in chronic SCI.

Focus groups of Y-K Delta Alaska Natives: attitudes toward tobacco use and tobacco dependence interventions

BACKGROUND

Tobacco dependence interventions developed for Alaska Natives are virtually nonexistent. Alaska Natives residing on the Yukon-Kuskokwim (Y--K) Delta in southwestern Alaska use a unique form of smokeless tobacco (ST) known as Iqmik. This study employed focus group methodology to explore attitudes toward tobacco use and tobacco dependence interventions among Alaska Natives residing on the Y-K Delta.

METHODS

Twelve focus groups of former and current tobacco users were conducted in four villages in the Y-K Delta. Participants were 35 adults (83% female) and 22 adolescents (27% female). Participants completed a brief demographic and tobacco use history form. Statements from the focus groups were transcribed for content coding and analysis of the major themes.

RESULTS

Use of Iqmik in the villages is thought to be ubiquitous. Y-K Delta Alaska Natives are introduced to Iqmik at a very young age. Iqmik is mostly used and prepared by young Alaska Natives and adult women. There are few perceived adverse health effects of Iqmik or other tobacco use. Although there is interest in stopping, there is a perceived lack of availability of tobacco dependence interventions. The major barriers to preventing the initiation of and stopping tobacco use are the social acceptance and widespread use and availability of tobacco.

CONCLUSION

The attitudes toward tobacco and identified barriers to stopping will be useful in developing tobacco dependence interventions for Alaska Natives.

Circulatory responses to progressive exercise: insights from positional differences

The influence of body position on cardiac responses to progressive exercise was examined in 13 healthy circumpubertal boys. The subjects (mean age 12.5 +/- 1.4 y) performed a progressive cycle test with an identical protocol in the sitting and supine positions. Stroke volume and left ventricular dimensions were assessed with Doppler and two-dimensional echocardiography, respectively. During supine exercise, no changes were seen in stroke volume or left ventricular preload (end-diastolic dimension) with increasing exercise intensity. At rest, mean values for stroke volume and cardiac output were 16.4 % and 27.1 % lower, respectively, with subjects upright compared to supine. With upright exercise these variables rose to become insignificantly different than supine values. Stroke volume while cycling upright rose by 29 % by the second workload but remained stable at higher work intensities. The initial increase in stroke volume observed only when cycling upright presumably reflects mobilization of dependent blood in the lower extremities. The mechanisms governing cardiac responses to exercise when supine and upright are otherwise identical.

Antipyretic therapy in patients with sepsis

Sepsis is a clinical syndrome characterized by a systemic inflammatory response to infection. Mortality rates in sepsis have remained high, despite recent advances in our understanding of the immunological mechanisms that cause sepsis. Fever, a nonspecific acute-phase response, has been associated with improved survival and shortened disease duration in some infections. This article reviews the biological effects of fever and the influence of antipyretic therapy on the outcome in sepsis in experimental models and in humans and offers clinical recommendations for antipyretic therapy in early and late stages of the disorder.