Effect of Deutetrabenazine on Chorea Among Patients With Huntington Disease: A Randomized Clinical Trial

IMPORTANCE

Deutetrabenazine is a novel molecule containing deuterium, which attenuates CYP2D6 metabolism and increases active metabolite half-lives and may therefore lead to stable systemic exposure while preserving key pharmacological activity.

OBJECTIVE

To evaluate efficacy and safety of deutetrabenazine treatment to control chorea associated with Huntington disease.

DESIGN, SETTING, AND PARTICIPANTS

Ninety ambulatory adults diagnosed with manifest Huntington disease and a baseline total maximal chorea score of 8 or higher (range, 0-28; lower score indicates less chorea) were enrolled from August 2013 to August 2014 and randomized to receive deutetrabenazine (n = 45) or placebo (n = 45) in a double-blind fashion at 34 Huntington Study Group sites.

INTERVENTIONS

Deutetrabenazine or placebo was titrated to optimal dose level over 8 weeks and maintained for 4 weeks, followed by a 1-week washout.

MAIN OUTCOMES AND MEASURES

Primary end point was the total maximal chorea score change from baseline (the average of values from the screening and day-0 visits) to maintenance therapy (the average of values from the week 9 and 12 visits) obtained by in-person visits. This study was designed to detect a 2.7-unit treatment difference in scores. The secondary end points, assessed hierarchically, were the proportion of patients who achieved treatment success on the Patient Global Impression of Change (PGIC) and on the Clinical Global Impression of Change (CGIC), the change in 36-Item Short Form- physical functioning subscale score (SF-36), and the change in the Berg Balance Test.

RESULTS

Ninety patients with Huntington disease (mean age, 53.7 years; 40 women [44.4%]) were enrolled. In the deutetrabenazine group, the mean total maximal chorea scores improved from 12.1 (95% CI, 11.2-12.9) to 7.7 (95% CI, 6.5-8.9), whereas in the placebo group, scores improved from 13.2 (95% CI, 12.2-14.3) to 11.3 (95% CI, 10.0-12.5); the mean between-group difference was -2.5 units (95% CI, -3.7 to -1.3) (P < .001). Treatment success, as measured by the PGIC, occurred in 23 patients (51%) in the deutetrabenazine group vs 9 (20%) in the placebo group (P = .002). As measured by the CGIC, treatment success occurred in 19 patients (42%) in the deutetrabenazine group vs 6 (13%) in the placebo group (P = .002). In the deutetrabenazine group, the mean SF-36 physical functioning subscale scores decreased from 47.5 (95% CI, 44.3-50.8) to 47.4 (44.3-50.5), whereas in the placebo group, scores decreased from 43.2 (95% CI, 40.2-46.3) to 39.9 (95% CI, 36.2-43.6), for a treatment benefit of 4.3 (95% CI, 0.4 to 8.3) (P = .03). There was no difference between groups (mean difference of 1.0 unit; 95% CI, -0.3 to 2.3; P = .14), for improvement in the Berg Balance Test, which improved by 2.2 units (95% CI, 1.3-3.1) in the deutetrabenazine group and by 1.3 units (95% CI, 0.4-2.2) in the placebo group. Adverse event rates were similar for deutetrabenazine and placebo, including depression, anxiety, and akathisia.

CONCLUSIONS AND RELEVANCE

Among patients with chorea associated with Huntington disease, the use of deutetrabenazine compared with placebo resulted in improved motor signs at 12 weeks. Further research is needed to assess the clinical importance of the effect size and to determine longer-term efficacy and safety.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01795859.

The Missing Link: Early Methane ("T") Dwarfs in the Sloan Digital Sky Survey

We report the discovery of three cool brown dwarfs that fall in the effective temperature gap between the latest L dwarfs currently known, with no methane absorption bands in the 1-2.5 µm range, and the previously known methane (T) dwarfs, whose spectra are dominated by methane and water. The newly discovered objects were detected as very red objects in the Sloan Digital Sky Survey imaging data and have JHK colors between the red L dwarfs and the blue Gl 229B-like T dwarfs. They show both CO and CH(4) absorption in their near-infrared spectra in addition to H(2)O, with weaker CH(4) absorption features in the H and K bands than those in all other methane dwarfs reported to date. Due to the presence of CH(4) in these bands, we propose that these objects are early T dwarfs. The three form part of the brown dwarf spectral sequence and fill in the large gap in the overall spectral sequence from the hottest main-sequence stars to the coolest methane dwarfs currently known.

Dust Emission from High-Redshift QSOs

We present detections of emission at 250 GHz (1.2 mm) from two high-redshift QSOs from the Sloan Digital Sky Survey sample using the bolometer array at the IRAM 30 m telescope. The sources are SDSSp 015048.83+004126.2 at z=3.7 and SDSSp J033829.31+002156.3 at z=5.0; the latter is the third highest redshift QSO known and the highest redshift millimeter-emitting source yet identified. We also present deep radio continuum imaging of these two sources at 1.4 GHz using the Very Large Array. The combination of centimeter and millimeter observations indicate that the 250 GHz emission is most likely thermal dust emission, with implied dust masses approximately 108 M middle dot in circle. We consider possible dust heating mechanisms, including UV emission from the active galactic nucleus (AGN) and a massive starburst concurrent with the AGN, with implied star formation rates greater than 103 M middle dot in circle yr-1.

The Discovery of a Second Field Methane Brown Dwarf from Sloan Digital Sky Survey Commissioning Data

We report the discovery of a second field methane brown dwarf from the commissioning data of the Sloan Digital Sky Survey (SDSS). The object, SDSS J134646.45-003150.4 (hereafter SDSS 1346-00), was selected because of its very red color and stellar appearance. Its spectrum between 0.8 and 2.5 µm is dominated by strong absorption bands of H2O and CH4 and closely mimics those of Gliese 229B and SDSS 162414.37+002915.6 (hereafter SDSS 1624+00), two other known methane brown dwarfs. SDSS 1346-00 is approximately 1.5 mag fainter than Gliese 229B, suggesting that it lies about 11 pc from the Sun. The ratio of flux at 2.1 µm to that at 1.27 µm is larger for SDSS 1346-00 than for Gliese 229B and SDSS 1624+00, which suggests that SDSS 1346-00 has a slightly higher effective temperature than the others. Based on a search area of 130 deg2 and a detection limit of z*=19.8, we estimate a space density of 0.05 pc-3 for methane brown dwarfs with Teff approximately 1000 K in the 40 pc3 volume of our search. This estimate is based on small-sample statistics and should be treated with appropriate caution.

The Discovery of a High-Redshift Quasar without Emission Lines from Sloan Digital Sky Survey Commissioning Data

We report observations of a luminous unresolved object at redshift z=4.62, with a featureless optical spectrum redward of the Lyalpha forest region, discovered from Sloan Digital Sky Survey commissioning data. The redshift is determined by the onset of the Lyalpha forest at lambda approximately 6800 Å and a Lyman limit system at lambda=5120 Å. A strong Lyalpha absorption system with weak metal absorption lines at z=4.58 is also identified in the spectrum. The object has a continuum absolute magnitude of -26.6 at 1450 Å in the rest frame (h0=0.5, q0=0.5) and therefore cannot be an ordinary galaxy. It shows no radio emission (the 3 sigma upper limit of its flux at 6 cm is 60 µJy), indicating a radio-to-optical flux ratio at least as small as that of the radio-weakest BL Lacertae objects known. It is also not linearly polarized to a 3 sigma upper limit of 4% in the observed I band. Therefore, it is either the most distant BL Lac object known to date, with very weak radio emission, or a new type of unbeamed quasar, whose broad emission line region is very weak or absent.

Long-term evolution of renal function in patients with ovarian cancer after whole abdominal irradiation with or without preceding cisplatin

BACKGROUND

The upper limit of the natural decline in creatinine clearance is 1 ml/min/year. To define the loss of renal function, we started a long-term assessment of patients with ovarian cancer treated by whole abdominal irradiation (WAI) with preceding cisplatin chemotherapy (CDDP) and second-look laparotomy (SLL).

PATIENTS AND METHODS

We analyzed the creatinine clearance over time of 56 patients treated from 1982 to 1988 for ovarian cancer. Thirty-one of 56 patients had received WAI after their initial surgery, and 25 of 56 patients had undergone CDDP therapy followed by SLL, and then WAI after their initial surgery. Median follow-up was 99 months (7-156). Twenty of 56 patients accepted our invitation for additional assessment of tubular function, nine of the 31 patients without CDDP therapy and SLL, and 11 of the 25 patients with CDDP followed by SLL and WAI. Ten of twenty patients had received four to six cycles CDDP, 80 mg/m2/cycle, and one patient nine cycles. The median total dose for each kidney was 1450 cGy (480-1690).

RESULTS

The mean creatinine clearance decreased from 84 ml/min to 66 ml/min. Seventy-six percent of the 25 patients who had undergone CDDP therapy, SLL and WAI had declines of more than 1 ml/min/year, 64% of these patients of more than 2 ml/min/year. For the 31 patients who had received WAI after their initial surgery, the corresponding numbers were 71% and 55%, respectively. The tubular function of the 20 patients who had undergone the additional investigations was not impaired.

CONCLUSION

The decline in renal function after WAI is more pronounced than in healthy subjects. The treatment with cisplatin and SLL prior to WAI does not seem to contribute to this loss of kidney function.

Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III)

A case-mix classification system for nursing home residents is developed, based on a sample of 7,658 residents in seven states. Data included a broad assessment of resident characteristics, corresponding to items of the Minimum Data Set, and detailed measurement of nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. The Resource Utilization Groups, Version III (RUG-III) system, with 44 distinct groups, achieves 55.5% variance explanation of total (nursing and therapy) per diem cost and meets goals of clinical validity and payment incentives. The mean resource use (case-mix index) of groups spans a nine-fold range. The RUG-III system improves on an earlier version not only by increasing the variance explanation (from 43%), but, more importantly, by identifying residents with "high tech" procedures (e.g., ventilators, respirators, and parenteral feeding) and those with cognitive impairments; by using better multiple activities of daily living; and by providing explicit qualifications for the Medicare nursing home benefit. RUG-III is being implemented for nursing home payment in 11 states (six as part of a federal multistate demonstration) and can be used in management, staffing level determination, and quality assurance.

Charged-coupled detector sky surveys

Sky surveys have played a fundamental role in advancing our understanding of the cosmos. The current pictures of stellar evolution and structure and kinematics of our Galaxy were made possible by the extensive photographic and spectrographic programs performed in the early part of the 20th century. The Palomar Sky Survey, completed in the 1950s, is still the principal source for many investigations. In the past few decades surveys have been undertaken at radio, millimeter, infrared, and x-ray wavelengths; each has provided insights into new astronomical phenomena (e.g., quasars, pulsars, and the 3 degrees cosmic background radiation). The advent of high quantum efficiency, linear solid-state devices, in particular charged-coupled detectors, has brought about a revolution in optical astronomy. With the recent development of large-format charged-coupled detectors and the rapidly increasing capabilities of data acquisition and processing systems, it is now feasible to employ the full capabilities of electronic detectors in projects that cover an appreciable fraction of the sky. This talk reviews the first "large scale" charged-coupled detector survey. This program, designed to detect very distant quasars, reveals the powers and limitations of charged-coupled detector surveys.

What the Longest Exposures from the Hubble Space Telescope Will Reveal

Detailed simulations are presented of the longest exposures on representative fields that will be obtained with the Hubble Space Telescope, as well as predictions for the numbers and types of objects that will be recorded with exposures of different durations. The Hubble Space Telescope will reveal the shapes, sizes, and content of faint, distant galaxies and could discover a new population of Galactic stars.

Case-mix classification of Medicare residents in skilled nursing facilities: resource utilization groups (RUG-T18)

Medicare residents in Skilled Nursing Facilities (SNFs) represent a small but unique population about which little is known. Data collected in a national sample of 2,564 Medicare residents in 38 SNFs were used to derive a resident classification system appropriate for use in a payment system. The classification system, Resource Utilization Groups-Medicare (RUG-T18) explains 55.5% of the per-diem resource cost differences of Medicare SNF residents. No classification system could be derived to provide significant explanation of per-episode costs. Although Medicare residents are admitted to SNFs immediately following an acute stay that is paid according to their diagnosis-related groups, the DRGs were ineffective in explaining SNF resource costs.

Case mix for nursing home payment: resource utilization groups, version II

A study of 3,427 nursing home residents in New York State, measuring both resources used and resident characteristics, was used to develop a resident classification system for payment purposes. The system balances clinical, statistical, and administrative criteria, making it useful both for the New York State Medicaid payment system and for quality of care and facility management.

Discovery of a New Gravitational Lens System

A new gravitational lens system, the triple radio source MG2016+112, has been discovered. Five emission lines at a redshift of 3.2733+/-0.0014 have been identified in the spectra of two stellar objects of magnitude 22.5 coincident with radio components 3.4 arc seconds apart. The lines are the narrowest ever observed in objects at such a large redshift. The redshift of a 23rd-magnitude extended optical object coincident with the third radio component has not been determined spectroscopically, but its known optical properties are consistent with those of a giant elliptical galaxy with a redshift of about 0.8.

A comparison of the level of care predictions of six long-term care patient assessment systems

Six patient assessment systems that have explicit decision rules for replicating team judgments on level of care patient placement were selected for analysis. The six were selected because of their origin, logic or decision diversity, and their ability to be programmed on a computer (i.e., explicit decision rules). Six hundred seventy-nine patient descriptor profiles were collected on patients currently in New York State nursing homes. These patients were then "placed" by level of care for each assessment system. The probability of agreement of placement between pairs of assessment systems ranges from 38 per cent to 91 per cent. Among SNF (skilled nursing facility) patients only, the level of agreement drops as low as 39 per cent. Uniformity of placement criteria is, in fact, the exception rather than the rule. A patient's placement is quite dependent on both his/her state of residence and his/her health status. The effect of differences in placement decisions has major implications for the patients being placed and for the cost of LTC (long-term care). This analysis was confined to systems that had a well developed set of guidelines--the situation is likely to be even more variable where guidelines are vaguely stated.

An analytical method for regional dental manpower training

This paper presents an analytical method for dental manpower planning for use by Health Systems Agencies. The planning methods discard geopolitical boundaries in favor of Dental Service Areas (DSA). A method for defining DSAs by aggregating Minor Civil Divisions based on current population mobility and current distribution of dentists is presented. The Dental Manpower Balance Model (DMBM) is presented to calculate shortages (or surpluses) of dentists. This model uses sociodemographic data to calculate the demand for dental services and age adjusted productivity measures to calculate the effective supply of dentists. A case study for the HSA region in Northeastern New York is presented. The case study demonstrates that, although the planning methods are quite simple, they are more flexible and produce more sensitive results than the normative ratio method of manpower planning.

A systems analysis of the impact of physician extenders on medical cost and manpower requirements

This paper presents a descriptive narrative of a mathematical manpower model and the results of an analysis of the effect physician extenders have on medical costs and manpower requirements. The model is extensively developed, through the use of a new medical classification system in the area of delegation of specific task areas and patient visits to physician extenders. Additionally the models incorporate a complete cost structure for a group practice. Field trials in seven HMOs indicate that the models accurately represent the actual system and can be used effectively as planning aids. Results are presented that analyze the use of physician extenders from the following viewpoints: minimum cost solution for adult medicine, pediatrics and obstetrics/gynecology (OB/GYN); maximum physician extender use; effect of physician extender salary on minimum cost utilization; level of independence exercised; size of clinic and regional manpower planning; and a case study of HMO planning. The type of results presented include cost analysis, manpower analysis, and the types of patient visits best delegated to physician extenders (PE).

A medical classification system for ambulatory-care manpower planning

The Trilevel Classification System described adapts the useful features of existing classification systems for convenient use in health manpower analysis. A computer program links the Kaiser Clinical-Behavioral Classification system, oriented to the demographic and socioeconomic characteristics of patient populations using ambulatory-care services, with the Geomet Specifications of Care, which in turn utilizes ICDA-coded records and Current Procedural Terminology—coded elements of care. An extensive case study is discussed in which the system is used in an HMO to predict the differential effects of various delegation policies for physician assistants.