Safety analyses of adalimumab (HUMIRA) in global clinical trials and US postmarketing surveillance of patients with rheumatoid arthritis

OBJECTIVE

To assess the safety of adalimumab in global clinical trials and postmarketing surveillance among patients with rheumatoid arthritis (RA).

METHODS

Safety data for adalimumab treated patients from randomised controlled trials, open label extensions, and two phase IIIb open label trials were analysed. In addition, postmarketing spontaneous reports of adverse events in the United States were collected following Food and Drug Administration approval of adalimumab on 31 December 2002.

RESULTS

As of 15 April 2005, the RA clinical trial safety database analysed covered 10,050 patients, representing 12,506 patient-years (PYs) of adalimumab exposure. The rate of serious infections, 5.1/100 PYs, was comparable to that reported on 31 August 2002 (4.9/100 PYs), and to published reports of RA populations naive to anti-tumour necrosis factor (TNF) therapy. Following implementation of tuberculosis (TB) screening in clinical trials, the rate of TB decreased. There were 34 cases of TB as of this analysis (0.27/100 PYs). The standardised incidence ratio for lymphoma was 3.19 (95% CI 1.78 to 5.26), consistent with the observed increased incidence in the general RA population. As of 30 June 2005, there were an estimated 78 522 PYs of exposure to adalimumab in the US postmarketing period. Seventeen TB cases were spontaneously reported (0.02/100 PYs) from the US. Rates of other postmarketing events of interest, such as congestive heart failure, systemic lupus erythematosus, opportunistic infections, blood dyscrasias, lymphomas, and demyelinating disease, support observations from clinical trials.

CONCLUSION

Analyses of these data demonstrate that long term adalimumab treatment is generally safe and well tolerated in patients with RA.

Social skills, social outcomes, and cognitive features of childhood social phobia

Social skills, social outcomes, self-talk, outcome expectancies, and self-evaluation of performance during social-evaluative tasks were examined with 27 clinically diagnosed social phobic children ages 7-14 and a matched nonclinical group. Results showed that, compared with their nonanxious peers, social phobic children demonstrated lower expected performance and a higher level of negative self-talk on social-evaluative tasks. In addition, social phobic children showed social skills deficits as assessed by self- and parent report, an assertiveness questionnaire, and direct behavioral observation. Furthermore, compared with the control group, social phobic children were rated by themselves and others as significantly less socially competent with peers and were found to be less likely to receive positive outcomes from peers during behavioral observation. Implications for the assessment and treatment of childhood social phobia are discussed.

Megacystis-microcolon-intestinal hypoperistalsis syndrome: a new cause of intestinal obstruction in the newborn. Report of radiologic findings in five newborn girls

Five newborn girls presented with small intestinal obstruction and microcolon and a giant bladder (megacystis). Organic causes of obstruction were not found, and the gastrointestinal tract failed to function after appropriate diversion. Two died in the postoperative period, two lived several months on central venous hyperalimentation, and one died at 34 months of age following chronic though intermittent hyperalimentation. Pathologic studies showed an abundance of ganglion cells in both dilated and narrowed areas of intestine; the combined small bowel-colon length was one-third of normal in the absence of an evident obstructive or vascular insult. The five patients represent the most severe manifestation of defective intestinal peristalsis in a larger group of distended newborns in whom organic gastrointestinal obstruction is not found. Treatment with central venous hyperalimentation may sustain life, and some patients eventually recover gastrointestinal function. The hypoperistalsis is largely refractory to pharmacologic treatment; its cause is unknown.

Animal and translational models of SARS-CoV-2 infection and COVID-19

COVID-19 is causing a major once-in-a-century global pandemic. The scientific and clinical community is in a race to define and develop effective preventions and treatments. The major features of disease are described but clinical trials have been hampered by competing interests, small scale, lack of defined patient cohorts and defined readouts. What is needed now is head-to-head comparison of existing drugs, testing of safety including in the background of predisposing chronic diseases, and the development of new and targeted preventions and treatments. This is most efficiently achieved using representative animal models of primary infection including in the background of chronic disease with validation of findings in primary human cells and tissues. We explore and discuss the diverse animal, cell and tissue models that are being used and developed and collectively recapitulate many critical aspects of disease manifestation in humans to develop and test new preventions and treatments.

Rosiglitazone does not improve cognition or global function when used as adjunctive therapy to AChE inhibitors in mild-to-moderate Alzheimer's disease: two phase 3 studies

INTRODUCTION

Two phase 3 studies evaluated the efficacy and safety of rosiglitazone (RSG), a type 2 diabetes treatment, in an extended release (RSG XR) form as adjunctive therapy to ongoing acetylcholine esterase inhibitor (AChEI) treatment in AD (REFLECT-2, adjunctive to donepezil; REFLECT-3, to any AChEI). An open-label extension study (REFLECT-4) assessed RSG XR long-term safety.

METHODS

In these two double-blind, placebo-controlled studies, subjects with mild-to-moderate probable AD were randomized within 2 apolipoprotein E (APOE) allelic strata (APOE ε4-positive, APOE ε4-negative) to once daily placebo, 2 mg RSG XR, or 8 mg RSG XR for 48 weeks (REFLECT-2, N=1,496; REFLECT-3, N=1,485). Co-primary efficacy endpoints were change from baseline in Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) and Clinical Dementia Rating scale - Sum of Boxes (CDR-SB) scores at week 48. Three populations were analyzed: APOE4-negative, all subjects except APOE ε4 homozygotes, and the full intent-to-treat population.

RESULTS

No statistically or clinically relevant differences between treatment groups were observed on the a priori primary endpoints in REFLECT-2 or REFLECT-3. Edema was the most frequent adverse event with RSG in each study (14% and 19%, respectively, at 8 mg RSG XR).

CONCLUSIONS

No evidence of statistically or clinically significant efficacy in cognition or global function was detected for 2 mg or 8 mg RSG XR as adjunctive therapy to ongoing AChEIs. There was no evidence of an interaction between treatment and APOE status. Safety and tolerability of RSG XR was consistent with the known profile of rosiglitazone.

Inhibition of T cell costimulation abrogates airway hyperresponsiveness in a murine model

Activation of naive T cells requires at least two signals. In addition to the well characterized interaction of the T cell antigen receptor with the antigen/MHC expressed on an antigen-presenting cell, T cell activation also requires costimulation by a second set of signals. The best characterized costimulatory receptor is CD28, which binds to a family of B7 ligands expressed on antigen-presenting cells. In asthma, although activated T cells play a role in the initiation and maintenance of airway inflammation, the importance of T cell costimulation in bronchial hyperresponsiveness had not been characterized. Therefore, we tested the hypothesis that inhibition of the CD28:B7 costimulatory pathway would abrogate airway hyperresponsiveness. Our results show that blockade of costimulation with CTLA4-Ig, a fusion protein known to prevent costimulation by blocking CD28:B7 interactions, inhibits airway hyperresponsiveness, inflammatory infiltration, expansion of thoracic lymphocytes, and allergen-specific responsiveness of thoracic T cells in this murine model of allergic asthma.

Problem-solving orientation and attributional style: moderators of the impact of negative life events on the development of depressive symptoms in adolescence?

Followed up 733 adolescents, ages 12 to 14 years, from a community sample over a 1-year period. Depressive symptoms at 1-year follow-up, controlling for baseline depression levels, were predicted by negative life events (NLEs) in the previous 12 months, attributional style (AS), negative problem solving orientation (NPSO), and the interaction between NLEs and NPSO. In the presence, but not absence, of high NLEs, NPSO predicted increases in depressive symptoms. In contrast, pessimistic AS predicted future increases in depression irrespective of the occurrence of NLEs. The findings supported a congnitive diathesis-stress model of the development of depression for NPSO but not AS.

Social skills, social outcomes, and cognitive features of childhood social phobia

Social skills, social outcomes, self-talk, outcome expectancies, and self-evaluation of performance during social-evaluative tasks were examined with 27 clinically diagnosed social phobic children ages 7-14 and a matched nonclinical group. Results showed that, compared with their nonanxious peers, social phobic children demonstrated lower expected performance and a higher level of negative self-talk on social-evaluative tasks. In addition, social phobic children showed social skills deficits as assessed by self- and parent report, an assertiveness questionnaire, and direct behavioral observation. Furthermore, compared with the control group, social phobic children were rated by themselves and others as significantly less socially competent with peers and were found to be less likely to receive positive outcomes from peers during behavioral observation. Implications for the assessment and treatment of childhood social phobia are discussed.

Improving the cancer chemotherapy use process

PURPOSE

Reports of the tragic consequences of erroneous cancer chemotherapy overdoses at a prominent cancer center and a university hospital prompted a review of our institution's practices and those of 123 other hospitals to ascertain for each the current in-house process to prevent chemotherapy errors.

METHODS

A multidisciplinary committee of oncologists, nurses, and pharmacists reviewed the chemotherapy use process and identified opportunities for improvement. A 1-page facsimile survey was answered by 150 of 215 members of the American Society of Clinical Oncology (ASCO) who received it.

RESULTS

We further restricted the writing of cytotoxic chemotherapy orders to physicians who were board-certified or -eligible in hematology or medical, pediatric, and gynecologic oncology and their approved fellows. Dispensation of drugs is limited to oncology-certified pharmacists, and administration to chemotherapy-certified nurses. Standard orders are used either on special oncology forms or designated order sets in the computer. Procedures to regulate the ordering of antineoplastic drugs for nonmalignant indications by nononcology specialists are outlined. A process to prevent chemotherapy errors is in place in 95% of hospitals. Dedicated medical oncology units are ubiquitous, and most cancer centers and university hospitals have dedicated gynecologic and pediatric oncology units. Chemotherapy orders are generally written by oncology fellows and countersigned by an attending oncologist in cancer centers and university hospitals, whereas private oncology attending physicians write them in most community hospitals. Drugs are administered by oncology-certified nurses in most institutions.

CONCLUSIONS

These recommendations should improve the safety and effective use of chemotherapy and reduce the error rate to as close to zero as human fallibility will allow.

Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders - an international consensus statement

BACKGROUND

Anxiety disorders in children and young people are common and bring significant personal and societal costs. Over the last two decades, there has been a substantial increase in research evaluating psychological and pharmacological treatments for anxiety disorders in children and young people and exciting and novel research has continued as the field strives to improve efficacy and effectiveness, and accessibility of interventions. This increase in research brings potential to draw together data across studies to compare treatment approaches and advance understanding of what works, how, and for whom. There are challenges to these efforts due largely to variation in studies' outcome measures and variation in the way study characteristics are reported, making it difficult to compare and/or combine studies, and this is likely to lead to faulty conclusions. Studies particularly vary in their reliance on child, parent, and/or assessor-based ratings across a range of outcomes, including remission of anxiety diagnosis, symptom reduction, and other domains of functioning (e.g., family relationships, peer relationships).

METHODS

To address these challenges, we convened a series of international activities that brought together the views of key stakeholders (i.e., researchers, mental health professionals, young people, parents/caregivers) to develop recommendations for outcome measurement to be used in treatment trials for anxiety disorders in children and young people.

RESULTS AND CONCLUSIONS

This article reports the results of these activities and offers recommendations for selection and reporting of outcome measures to (a) guide future research and (b) improve communication of what has been measured and reported. We offer these recommendations to promote international consistency in trial reporting and to enable the field to take full advantage of the great opportunities that come from data sharing going forward.

Goat-associated Q fever: a new disease in Newfoundland

In the spring of 1999 in rural Newfoundland, abortions in goats were associated with illness in goat workers. An epidemiologic investigation and a serologic survey were conducted in April 1999 to determine the number of infections, nature of illness, and risk factors for infection. Thirty-seven percent of the outbreak cohort had antibody titers to phase II Coxiella burnetii antigen >1:64, suggesting recent infection. The predominant clinical manifestation of Q fever was an acute febrile illness. Independent risk factors for infection included contact with goat placenta, smoking tobacco, and eating cheese made from pasteurized goat milk. This outbreak raises questions about management of such outbreaks, interprovincial sale and movement of domestic ungulates, and the need for discussion between public health practitioners and the dairy industry on control of this highly infectious organism.

Cerebrospinal fluid eicosanoid levels: endogenous PGD2 and LTC4 synthesis by antigen-presenting cells that migrate to the central nervous system

We analyzed CSF from patients with multiple sclerosis, patients with other neurologic diseases, and healthy controls for the presence of prostaglandin (PG) E2, F2 alpha, D2, I, A, and leukotriene (LT) C4. Control CSF had little measurable PGs or LTs. CSF eicosanoids from patients with progressive MS were increased. We found PGD2 only in MS CSF. CSF monocytes from patients in active disease produced significantly increased PGD, PGE, and LTC4 than paired peripheral blood monocytes and monocytes from healthy controls. We saw no significant difference in LTC4 production between MS and control peripheral blood monocytes.

Surveillance transbronchial lung biopsies: implication for survival after lung transplantation

OBJECTIVES

We wished to determine whether early rejection after lung transplantation as assessed by surveillance transbronchial biopsy predicts for survival.

METHODS

Between 1990 and 1997, 96 consecutive patients had lung transplantation: 89 had a minimum 1-month follow-up. For 71 consecutive patients we have 1-year follow-up and for 69 patients we have the results of the first 3 biopsies. Cytomegalovirus status, bronchiolitis obliterans prevalence, and use of total lymphoid irradiation are noted. Biopsies were done at 1 week and 1, 3, and 6 months. Standard immunosuppression consisted of induction antilymphocyte globulin and high-dose methylprednisolone induction for 1 week and standard maintenance triple therapy. Acute rejection treatment was with pulse methylprednisolone. Bronchiolitis obliterans syndrome was treated with total lymphoid irradiation and a change to tacrolimus and mycophenolate. Blinded grading using International Society for Heart and Lung Transplantation classification was done retrospectively.

RESULTS

Survival at 1 month and 1, 2, and 3 years for the 96-patient cohort with 1-year follow-up was 93%, 74%, 62%, and 56%. Survival was not significantly different for subsets with rejection on any combination of the first 3 biopsies (1/3, 2/3, 3/3) or absence of rejection on the first 3 biopsies. Ninety-one positive biopsy results were graded. Eighteen of 71 patients had one or more moderate or severe rejection episodes without survival difference relative to the others. There was no statistically significant association between acute rejection on the first 3 surveillance biopsy results and bronchiolitis obliterans.

CONCLUSIONS

Intensive induction and maintenance immunotherapy with surveillance transbronchial biopsies and aggressive treatment of acute rejection is associated with a survival similar to that of patients without early acute rejection. This regimen appears to uncouple the association between early acute rejection and bronchiolitis obliterans. Further study may elucidate this mechanism.

The development and psychometric properties of a measure of social and adaptive functioning for children and adolescents

Developed, piloted, and examined the psychometric properties of the Child and Adolescent Social and Adaptive Functioning Scale (CASAFS), a self-report measure designed to examine the social functioning of young people in the areas of school performance, peer relationships, family relationships, and home duties/self-care. The findings of confirmatory and exploratory factor analysis support a 4-factor solution consistent with the hypothesized domains. Fit indexes suggested that the 4-correlated factor model represented a satisfactory solution for the data, with the covariation between factors being satisfactorily explained by a single, higher order factor reflecting social and adaptive functioning in general. The internal consistency and 12-month test-retest reliability of the total scale was acceptable. A significant, negative correlation was found between the CASAFS and a measure of depressive symptoms, showing that high levels of social functioning are associated with low levels of depression. Significant differences in CASAFS total and subscale scores were found between clinically depressed adolescents and a matched sample of nonclinical controls. Adolescents who reported elevated but subclinical levels of depression also reported lower levels of social functioning in comparison to nonclinical controls.

Teenagers' views on general practice consultations and other medical advice. The Adolescent Working Group, RCGP

BACKGROUND

The provision of health services for teenagers is of current interest in relation to primary care.

OBJECTIVES

The main objective of the study was to look at satisfaction with the teenager's last consultation and any reasons for dissatisfaction. A further objective was to look at common teenage health concerns to identify how many teenagers had been concerned about them, where they sought advice, and to look at ratings of this advice.

METHOD

Questionnaires were completed as part of a continuing evaluation of a novel sex education programme in 38 schools in 1997 and provided the data. The particular items reported in this study were related to satisfaction with the last GP consultation and reasons for dissatisfaction, health concerns and who (if anybody) was approached to address these concerns, and comments on services used. 5152 teenagers (51.8% male and 47.8% female) completed the questionnaires in a school lesson under conditions of complete confidentiality.

RESULTS

Over 86% of adolescents were apparently satisfied with their last consultation with a GP, although several possible reasons were identified for any dissatisfaction. Health concerns were identified and sources of help were considered and compared; no obvious levels of relative dissatisfaction with services were noted. A large number of teenagers identified apparent concerns but did not seek help for these concerns.

CONCLUSIONS

Adolescents are largely satisfied with the services available in primary care. A number of teenagers do not seek help for their own individual concerns. Encouraging teenagers to attend when they perceive a health problem may help provide a more sensitive primary care service.

Clinic audit for long-term survivors of childhood cancer

Follow up for survivors of childhood cancer is considered essential in order to document any continuing impact on growth, fertility and other systems, as well as provide appropriate care and information to individuals themselves. Appropriate follow up needs to take into account the survivors' own views about reasons for attendance and perceived satisfaction with the services provided. Information was sought from 93 survivors (more than five years from diagnosis) and 68 of their parents regarding current attendance, understanding of the purpose of the clinic and satisfaction, and future preferences. Patients' main reasons for attending were to gain reassurance that they were well and information about the disease. There were some discrepancies between the types of information patients would like from clinic attendance and what they remembered being given. Parents were more positive than patients. Our data suggest that (i) knowledge in survivors is poor and (ii) it may be possible to define a subgroup for whom less frequent follow up is appropriate. A key component of care must involve education of patients, both about their past and the implications for future health.

Obesity in Adults: A 2022 Adapted Clinical Practice Guideline for Ireland

BACKGROUND

This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity.

SUMMARY

It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients' lived experiences; move beyond simplistic approaches of "eat less, move more" and address the root drivers of obesity.

KEY MESSAGES

People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay.

Don't stop till you get enough: Factors driving men towards muscularity

This study tested a modified Tripartite Influence Model with 307 men (age M=27.05; SD=6.25). Sociocultural influences (media and male peers) were predicted to be associated with both internalisation of the muscular ideal and body comparisons, which in turn were predicted to be associated with muscle dissatisfaction and then drive for muscularity behaviours. The model was only partially supported. The results suggested that, contrary to what was predicted, muscle dissatisfaction was not related to drive for muscularity behaviours. Instead, internalisation of the muscular ideal was found to lead to body comparisons, which in turn were found to lead to drive for muscularity behaviours. In addition, internalisation and male peer influence were found to lead to muscle dissatisfaction; male peer influence and internalisation were found to lead to body comparisons; and both media and male peer influences were found to lead to internalisation.

Navigating the development and dissemination of internet cognitive behavioral therapy (iCBT) for anxiety disorders in children and young people: A consensus statement with recommendations from the #iCBTLorentz Workshop Group

Initial internet-based cognitive behavioral therapy (iCBT) programs for anxiety disorders in children and young people (CYP) have been developed and evaluated, however these have not yet been widely adopted in routine practice. The lack of guidance and formalized approaches to the development and dissemination of iCBT has arguably contributed to the difficulty in developing iCBT that is scalable and sustainable beyond academic evaluation and that can ultimately be adopted by healthcare providers. This paper presents a consensus statement and recommendations from a workshop of international experts in CYP anxiety and iCBT (#iCBTLorentz Workshop Group) on the development, evaluation, engagement and dissemination of iCBT for anxiety in CYP.

Spectrum of acute dissection of the ascending aorta: a transesophageal echocardiographic study

Transesophageal echocardiography is an accurate tool for the immediate diagnosis of acute aortic dissection. In addition to establishing the diagnosis of dissection, transesophageal echocardiography provides determination of its extent and detection of complications. The purpose of this study was to delineate the full spectrum of abnormalities present in acute dissection of the ascending aorta as assessed by transesophageal echocardiography. Forty consecutive patients with acute ascending aortic dissection were evaluated. Specific attention was paid to complications of aortic valve insufficiency, pericardial effusion, and left ventricular wall motion abnormalities. The aortic arch and the descending aorta were also evaluated for involvement. Quantitative data included measurement of the aorta at the anulus, sinuses, and tubular portion, as well as the proximal and distal descending aortas. An intimal flap was identified in all patients. This was a simple linear tear in 22 patients (55%) and circumferential in eight (20%). A complex tear was noted in 10 patients (25%). The majority of patients (n = 30; 75%) had extension of the dissection into the descending thoracic aorta. At least one communication between the true and false lumens ("entrance point") was identified in 31 patients (78%). Pericardial effusions were noted in 19 patients (48%), only two of whom had a moderate-size effusion. Moderate or severe aortic insufficiency was seen in 18 patients (45%) and regional wall motion abnormalities in six patients. We conclude that acute dissection of the ascending aorta results in a complex or convoluted flap rather than a simple linear tear in many patients. The complication of clinically significant pericardial effusion was rare. Aortic insufficiency is common and can be attributed to multiple mechanisms.

Dopaminergic nature of feeding-induced behavioral stereotypies in stressed pigeons

Dopamine dependence of feeding-induced behavioral stereotypies (FIBS) was demonstrated by FIBS facilitation following chronic treatment with a dopamine (DA) agonist, apomorphine, and by FIBS inhibition following the administration of haloperidol, a DA antagonist. However, individuals that emitted FIBS were differentiated from those not emitting FIBS not by assayed telencephalic DA concentrations alone but by a higher stereotyping index (SI), a score positively related to the ratio of telencephalic DA-norepinephrine (NE) concentrations. These latter findings support the hypothesis of Antelman and Caggiula [3] which indicates that a catecholamine interaction in the brain serves to facilitate or inhibit some behavioral actions associated with stress.

Teenagers in hospital: what do they want?

A questionnaire based survey undertaken in north London secondary schools supported the need for designated hospital facilities for teenagers: 53 per cent of young people who had been admitted to a paediatric ward, and 81 per cent of those admitted to an adult ward, had felt out of place there; 77 per cent of the total (347 adolescents) surveyed, thought a specific teenagers' room would be an improvement in service. In this article, the authors present the research.

A review of the literature examining the relationship between alcohol use and HIV-related sexual risk-taking in young people

Young people have been targeted as a potentially vulnerable population for the spread of HIV. The influence of alcohol on sexual behaviour is part of popular knowledge. More recently, studies have attempted to illuminate the relationship between alcohol use and sexual risk-taking in relation to HIV transmission. In our review of the literature three important points are highlighted for researchers in this area. First, methodological problems make establishing any relationship extremely difficult. Secondly, the concept of sexual risk-taking has to be developed to include acknowledgement of the context in which sex takes place rather than defining risk only in terms of sexual acts. Finally, populations of gay men and men who have sex with men and lesbians are sufficiently different from heterosexuals, with regard to the influence of alcohol on sexual behaviour, to make generalizations about one population inappropriate for the other.

Diagnosis of congenital antral web by ultrasound

Historically, the first case of congenital prepyloric membrane in an infant was documented in 1933 [1]. Since then cases have been reported only sporadically in the literature [2-8]. This is a case of congenital antral web which was identified by real-time ultrasonography, confirmed by barium meal study, and proven at gastrotomy.