The JAK inhibitor tofacitinib suppresses synovial JAK1-STAT signalling in rheumatoid arthritis

OBJECTIVE

Tofacitinib is an oral Janus kinase (JAK) inhibitor for the treatment of rheumatoid arthritis (RA). The pathways affected by tofacitinib and the effects on gene expression in situ are unknown. Therefore, tofacitinib effects on synovial pathobiology were investigated.

METHODS

A randomised, double-blind, phase II serial synovial biopsy study (A3921073; NCT00976599) in patients with RA with an inadequate methotrexate response. Patients on background methotrexate received tofacitinib 10 mg twice daily or placebo for 28 days. Synovial biopsies were performed on Days -7 and 28 and analysed by immunoassay or quantitative PCR. Clinical response was determined by disease activity score and European League Against Rheumatism (EULAR) response on Day 28 in A3921073, and at Month 3 in a long-term extension study (A3921024; NCT00413699).

RESULTS

Tofacitinib exposure led to EULAR moderate to good responses (11/14 patients), while placebo was ineffective (1/14 patients) on Day 28. Tofacitinib treatment significantly reduced synovial mRNA expression of matrix metalloproteinase (MMP)-1 and MMP-3 (p<0.05) and chemokines CCL2, CXCL10 and CXCL13 (p<0.05). No overall changes were observed in synovial inflammation score or the presence of T cells, B cells or macrophages. Changes in synovial phosphorylation of signal transducer and activator of transcription 1 (STAT1) and STAT3 strongly correlated with 4-month clinical responses (p<0.002). Tofacitinib significantly decreased plasma CXCL10 (p<0.005) at Day 28 compared with placebo.

CONCLUSIONS

Tofacitinib reduces metalloproteinase and interferon-regulated gene expression in rheumatoid synovium, and clinical improvement correlates with reductions in STAT1 and STAT3 phosphorylation. JAK1-mediated interferon and interleukin-6 signalling likely play a key role in the synovial response.

TRIAL REGISTRATION NUMBER

NCT00976599.

Occupation in lifestyle redesign: the Well Elderly Study Occupational Therapy Program

This article describes an innovative preventive occupational therapy intervention for well older adults, the Well Elderly Treatment Program. In a previously reported large-scale randomized effectiveness study, this intervention was found to be highly successful in enhancing the physical and mental health, occupational functioning, and life satisfaction of multicultural, community-dwelling elders. In this article, the philosophical background, manner of development, topical content, methods of program delivery, and mechanisms underlying the program's positive effects are discussed, along with implications for occupational therapy practice. The treatment was based on application of occupational science theory and research and emphasized the therapeutic process of lifestyle redesign in enabling the participants to actively and strategically select an individualized pattern of personally satisfying and health-promoting occupations. The wide-ranging effectiveness of the program supports the occupational therapy profession's emphasis on occupation in affecting health and positions practitioners to extend their services to the realm of preventive interventions.

Embedding health-promoting changes into the daily lives of independent-living older adults: long-term follow-up of occupational therapy intervention

The Well Elderly Study was a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to a 9-month program in preventive occupational therapy (OT). All participants completing the trial were followed for an additional 6 months without further intervention and then reevaluated using the same battery of instruments. Long-term benefit attributable to preventive OT was found for the quality of interaction scale of the Functional Status Questionnaire and for six of eight scales on the RAND SF-36: physical functioning, role functioning, vitality, social functioning, role emotional, and general mental health (p<.05). Approximately 90% of the therapeutic gain observed following OT treatment was retained in follow-up. The finding of a sustained effect for preventive OT is of great public health relevance given the looming health care cost crisis associated with our nation's expanding elderly population.

Increased cord serum inflammatory markers in small-for-gestational-age neonates

OBJECTIVE

The pathological picture in ischemic tissue injury shares features with the inflammatory response. Hypoxia-mediated induction of interleukin-6 (IL-6) could set in motion the mechanisms limiting inflammation in ischemia. Intrauterine growth restriction (IUGR) represents a human model of chronic fetal hypoxia. The purpose of this study was a first-time exploration to determine whether cord blood obtained at the delivery of small-for-gestational-age (SGA) infants has increased concentrations of inflammatory markers.

STUDY DESIGN

Cord blood was collected from 20 SGA (term and near-term) infants and 20 appropriate-for-gestational-age (AGA) controls. Infants exposed to maternal smoking, diabetes, maternal chronic diseases, or alcohol or drug use were excluded. Both groups had Apgar score ≥7 at 1 min with a normal cord pH (>7.25). Cord-serum cytokines and thrombopoietin (TPO) levels were measured by enzyme linked immunosorbent assay. C-reactive protein (CRP) was measured using a turbidometric immunoassay.

RESULT

SGA infants had a significantly smaller birth weight than AGA controls, with a smaller gestation age by 1 week. There were significant elevations in IL-6, tumor necrosis factor (TNF-α), CRP and TPO in the SGA compared with the AGA group, which persisted in multiple regression analysis even after gestational age was taken into account.

CONCLUSION

As hypothesized, significant increases in the cord blood concentrations of known inflammatory markers were found in SGA infants compared with the controls.

Denosumab-mediated increase in hand bone mineral density associated with decreased progression of bone erosion in rheumatoid arthritis patients

OBJECTIVE

Periarticular osteoporosis is one of the earliest radiographic signs of bone damage in rheumatoid arthritis (RA). Denosumab, an investigational fully human monoclonal antibody that binds to RANKL, inhibits bone erosion and systemic bone loss in clinical studies of patients with RA. In this hand bone mineral density (BMD) substudy, we investigated the effects of denosumab on hand BMD and its correlation with hand erosion scores.

METHODS

Patients receiving methotrexate for erosive RA were randomized in a 1:1:1 ratio to receive subcutaneous placebo, denosumab 60 mg, or denosumab 180 mg at 0 and 6 months. Measurements included BMD (by dual x-ray absorptiometry [DXA]) of both hands (0, 1, 6, and 12 months), magnetic resonance images of the hands/wrists (0 and 6 months), and radiographs of the hands/wrists and feet (0, 6, and 12 months).

RESULTS

There were 56 patients (13 placebo, 21 denosumab 60 mg, and 22 denosumab 180 mg). Mean changes in hand BMD at 6 and 12 months were: +0.8% and +1.0%, respectively, for denosumab 60 mg; +2.0% and +2.5%, respectively, for denosumab 180 mg; and -1.2% and -2.0%, respectively, for placebo. Erosion scores remained near baseline in the denosumab groups and increased from baseline in the placebo group. A negative correlation was observed between hand BMD and erosion scores.

CONCLUSION

In patients with RA, denosumab provided protection against erosion, and not only prevented bone loss but increased hand BMD as measured by DXA.

Lack of efficacy of thermography as a screening tool for minimal and stage I breast cancer

In a study of thermograms of 42 patients with Stage 1 or smaller carcinomas of the breast, 44 confounding cases and 64 randomly selected subjects being screened, we found that the ability of expert thermographers to identify the patients with carcinoma correctly (true positive = 0.238) varied little from the ability of untrained readers (true positive = 0.301). Furthermore, in the expert group, the indexes of suspicion were so high (0.436) and the true-positive levels were so relatively low (0.238, P = 0.0005) that thermography may well have a very limited role as a screening or pre-screening modality for the detection of minimal or Stage 1 breast cancers.

Major losses of fat, carbohydrates and energy content of preterm human milk frozen at -80°C

OBJECTIVE

Long-term storage of human milk (HM) requires freezing at low temperatures, the consequences of which upon macronutrients are unclear. To test the null hypothesis that HM freezing and storage for a range of 1 to 10 weeks at -80 °C does not affect HM fat, protein, lactose and energy contents.

STUDY DESIGN

Samples of HM were obtained from 20 mothers (60 samples) of preterm infants (25 to 35 weeks gestation), who routinely expressed their milk, every 3 h, using an electric pump, from the second to the seventh week after delivery. All samples were frozen at -80 °C for 8 to 83 days (43.8 days average). After thawing and homogenization, energy and macronutrient contents were measured using an HM analyzer.

RESULT

Fat, carbohydrates and energy contents were significantly lower in thawed HM than in fresh HM (fat, fresh vs thawed: 3.72±1.17 vs 3.36±1.19 g/100 ml, P<0.001; carbohydrates, fresh vs thawed: 5.86±0.71 vs 4.09±0.96 g/100 ml, P<0.001; energy, fresh vs thawed: 64.93±12.97 vs 56.63±16.82 kcal/100 ml, P<0.0001), whereas protein content remained unchanged (protein, fresh vs thawed: 1.14±0.36 vs 1.15±0.37 g/100 ml, P=0.7). The decline in carbohydrates content but not in fat and energy correlated significantly with freezing duration.

CONCLUSION

Freezing at -80 °C significantly decreases the energy content of HM, both from fat and carbohydrates. Since quantitatively the decrease in macronutrients was much higher than that published for HM storage at -20 °C, our results do not support freezing HM at -80 °C as the gold standard for long-term storage. We suggest that caloric intake calculations in preterm infants cannot be established based upon fresh HM data.

Life domains and adaptive strategies of a group of low-income, well older adults

Older adults are at increased risk for a variety of physical and functional limitations that threaten their ability to lead independent and fulfilling lives. Consequently, they stand to benefit from personalized strategies of adaptation that enable them to achieve successful outcomes in their daily activities and desired goals. In the current investigation, a qualitative descriptive methodology was used to document the perceived life domains of importance and associated strategies of adaptation of 29 residents of Angelus Plaza, a federally subsidized apartment complex in downtown Los Angeles for low-income, well older adults. On the basis of interview data, 10 life domains were identified, and within each domain, a typology of adaptive strategies was derived. The domains were activities of daily living (ADL), adaptation to a multicultural environment, free time usage, grave illness and death-spirituality, health maintenance, mobility maintenance, personal finances, personal safety, psychological well-being and happiness, and relationships with others. Although the typology should not be generalized to a geriatric population, therapists may wish to refer to it to gain a sense of the extent to which certain adaptive strategies may be applicable to the lives of particular older adults to whom they deliver services. The teaching of these adaptive strategies could then be incorporated into an individualized treatment plan. The typology also provides a broad picture of the kinds of adaptive strategies used by the older adults as a way of coping and adapting to their setting. Although some of the domains do not differ from those typically addressed in occupational therapy textbooks on geriatric care (e.g., ADL, health maintenance), others seem uniquely tailored to the specifics of the Angelus Plaza context (e.g., personal safety). Finally, certain domains emerged that may be highly relevant to older adults in most settings but are not typically the focus of occupational therapy programs (e.g., grave illness and death-spirituality, relationships with others). The emergence of these domains from our data suggests that therapists may wish to consider them more in treatment if they are convinced that they possess local relevance.

Cold weather training: a risk factor for Achilles paratendinitis among recruits

In a prospective study of risk factors for Achilles tendinopathy among four induction cycles of infantry recruits, 95 out of 1405 recruits, (6.8%) were found to suffer from Achilles tendinopathy. In more than 94% of the cases, the tendinopathy was considered to be paratendinitis. Training season had a statistically significant effect on the incidence of Achilles paratendinitis with 3.6% suffering in the summer and 9.4% in the winter (p = .001). This increased risk for Achilles paratendinitis in cold weather outdoor training can be explained by a fall in temperature of the Achilles paratenon whose membranes are rich in mucopolysaccharides and serve as a lubricant for gliding of the tendon and epitenon. Decreased temperature may increase the viscosity of the lubricant and thereby increases friction and risk for Achilles paratendinitis. This same relationship illustrates why "warming up" before exercising may be important in lowering the incidence of Achilles paratendinitis.

The effect of maternal habitus on macronutrient content of human milk colostrum

OBJECTIVE

There is a paucity of studies on the impact of maternal body mass index (BMI) on macronutrient content of human milk colostrum (HMC). The objective of this study was to compare macronutrient content of HMC in healthy women of term infants in relation to their BMI. We hypothesized that mother habitus influences human milk colostrum content.

METHOD

Colostrum was collected from 109 healthy mothers of hospitalized healthy term infants divided into four prepregnancy BMI groups: 12 underweight, 59 normal weight, 20 overweight, and 18 obese women between 24 and 72 h after birth. Macronutrient content was measured using mid-infrared spectroscopy.

RESULTS

There were no significant differences in macronutrients between the BMI groups. We performed four separate stepwise backward multiple regression analyses taking into account fat, carbohydrate, protein or energy content as dependent variables and maternal BMI, parity, gestational age, infant gender, maternal age, maternal education, mode of delivery and time postdelivery. In these analyses, fat, carbohydrate and energy content were not related to maternal BMI, while protein content was significantly and positively correlated with BMI (P=0.008) and negatively correlated with gestational age (P=0.004) and time postdelivery (P<0.001). Colostrum carbohydrate content was positively correlated with parity. Colostrum fat and energy content were negatively correlated with maternal age and positively correlated with parity.

CONCLUSION

Most macronutrient and energy content of colostrum are unaffected by prepregnancy maternal BMI, with the exception of protein content that is positively related to maternal BMI.

Psychometric properties of a Chinese translation of the SF-36 health survey questionnaire in the Well Elderly Study

OBJECTIVES

To evaluate the psychometric properties of a Chinese translation of the 36-item Short Form Health Survey (SF-36) in the Well Elderly Study--a randomized clinical trial designed to evaluate the effectiveness of preventive occupational therapy services specifically tailored for multiethnic, independent-living, older adults.

METHODS

Translation and back-translation procedures were used to obtain appropriate meanings for the SF-36 survey questions and to ensure face, functional, and conceptual equivalence.

RESULTS

Statistical analyses demonstrated satisfactory reliability and validity, with the results generally similar to those reported for older Anglo adults.

DISCUSSION

As the percentage of older adults of diverse ethnicity increases, the need for health care research and service strategies that can effectively include multiple ethnicities becomes paramount. The results of this study suggest that a Chinese-translated SF-36 can be used to assess multiple dimensions of health in a Mandarin-speaking population of older adults.

Bach music in preterm infants: no 'Mozart effect' on resting energy expenditure

OBJECTIVE

To study whether Johan Sebastian Bach music has a lowering effect on resting energy expenditure (REE) similar to that of Wolfgang Amadeus Mozart music.

STUDY DESIGN

Prospective, randomized clinical trial with cross-over in 12 healthy, appropriate weights for gestational age (GA), gavage fed, metabolically stable, preterm infants. Infants were randomized to a 30-min period of either Mozart or Bach music or no music over 3 consecutive days. REE was measured every minute by indirect calorimetry.

RESULT

Three REE measurements were performed in each of 12 infants at age 20±15.8 days. Mean GA was 30.17±2.44 weeks and mean birthweight was 1246±239 g. REE was similar during the first 10-min of all three randomization periods. During the next 10-min period, infants exposed to music by Mozart had a trend toward lower REE than when not exposed to music. This trend became significant during the third 10-min period. In contrast, music by Bach or no music did not affect significantly REE during the whole study. On average, the effect size of Mozart music upon REE was a reduction of 7.7% from baseline.

CONCLUSION

Mozart music significantly lowers REE in preterm infants, whereas Bach music has no similar effect. We speculate that 'Mozart effect' must be taken into account when incorporating music in the therapy of preterm infants, as not all types of music may have similar effects upon REE and growth.

Conclusiveness of the Cochrane reviews in nutrition: a systematic analysis

BACKGROUND/OBJECTIVE

To assess the conclusiveness of the Cochrane Reviews (CRs) in the field of Nutrition, we tested the hypotheses that: (1) the majority of CRs is inconclusive; (2) the majority of CRs recognizes the need for further and better studies and (3) the ability to reach a conclusion is dependent on the number of studies performed and number of patients enrolled.

SUBJECTS/METHODS

We selected all 87 CRs in the field of Nutrition available in Cochrane library. Each CR was analyzed for the number of randomized clinical trials (RCTs) found, number of RCTs included for analysis, number of patients enrolled, the stated need for further studies and the reason(s) for it and the conclusiveness of the CR.

RESULTS

Fifty-six out of eighty-seven CRs (64.4%) were conclusive. The average number of available articles, the percentage of articles included, the average number of RCT's retained in the analyses and the total cumulative number of patients enrolled in the studies retained for analysis were significantly higher in conclusive CRs than in non-conclusive ones. The majority of inconclusive CRs (70.9%) recognized the need for further studies, a percentage not significantly different from that found in conclusive ones (58.9%, P=0.26). The percentage of conclusive CRs was not affected by year of publication.

CONCLUSIONS

The majority of CRs in Nutrition is conclusive, but most of them emphasize the need for further studies. The ability for a CR to reach a conclusion is affected by the cumulative patient sample size and number of RCT's included in the analysis.

Sipple's syndrome with a malignant pheochromocytoma presenting as a pericardial effusion

Sipple's syndrome is a multiple endocrinopathy usually involving the adrenal medulla and the thyroid. In the present case, a malignant pheochromocytoma metastasized to the pericardium and both lungs. The patient was known to have had a calcified right suprarenal mass for 8 years. He was admitted to the emergency room with symptomatology consistent with pericardial tamponade, but despite intensive management, he expired.

Breast milk fat content of mothers to small-for-gestational-age infants

OBJECTIVE

Little is known about the composition of human milk (HM) expressed by mothers of asymmetrically growth-restricted infants. To test the null hypothesis that lactating mothers of small-for-gestational-age (SGA) infants produce milk with fat content similar to that of lactating mothers of infants whose growth is appropriate for gestational age (AGA).

STUDY DESIGN

Fifty-six lactating mothers of newborns (26 SGA and 30 AGA) were recruited within the first 3 days of delivery. Creamatocrit (CMT) levels in HM were measured at 72 h, 7 days and 14 days postdelivery in capillary tubes after centrifugation at 9000 r.p.m. for 5 min.

RESULT

The groups did not differ in terms of maternal age, body mass index, gestational age (GA), pregnancy weight gain and parity. They differed significantly in terms of infant's birth weight by design. The mean CMT levels at the three time points were similar for the two groups. This remained true when timing of the sample (colostrum, transitional, mature milk) was introduced as a confounder in the analysis of variance (general linear model).

CONCLUSION

Fat content of HM is not affected by fetal growth status. We suggest that mothers of SGA infants may be reassured that their milk contains adequate amount of fat that is appropriate for the growth of their infants.

Double catheter technique for misdirected umbilical vein catheter

We studied the success rate of the double catheter technique during umbilical vein catheter placement in 42 patients with a misdirected umbilical vein catheter. The misdirected catheter was left in place, and an additional catheter was inserted. X-ray films confirmed that successful placement was achieved in 50% of infants without significant adverse effects.

Size fractionation of thermal aggregates of immunoglobulin G

Purified pooled human immunoglobulin G (IgG) in solution, when extensively heated at high temperatures or for long periods, irreversibly aggregates and insoluble precipitates result. However, when IgG solutions are heated in the temperature range 55-65 degrees C for more limited time periods, soluble turbid polydispersed aggregate mixtures are obtained. Gel filtration of such aggregate mixtures on calibrated Bio-Rad A-150m columns demonstrates a continuous size distribution from dimers to aggregates as large as 4 X 10(7) Da (200-mers) with no particular size predominant. Chromatographically reproducible cuts of narrow size heterogeneity can be obtained by short-time fraction collection. Elution-time reproducibility is excellent both for mixture and for individual cuts. Stability studies indicate that reproducible and stable aggregates may be made from purified IgG and that fractionated aggregates should be stored quick-frozen until needed. Sized IgG aggregates have proved useful in reactivity studies with rheumatoid factor, animal anti-IgG antibodies, and complement.

Derivation and pilot assessment of a health promotion program for Mandarin-speaking Chinese older adults

As the percentage of older adults of diverse ethnicities increases in the United States, the call for culturally sensitive health care service strategies that target the special needs of older people grows. The present report describes methods used to adapt a health care program so that it would better meet the needs of a group of well, older Mandarin-speaking Chinese residents of Los Angeles. The specific qualitative research procedures that we used to adapt the treatment program are described, along with the particular adaptations that emerged. Additionally, outcomes from a randomized pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among older Mandarin-speaking men and women. The overall outcome of this project is in agreement with other reports in the health care literature that address the importance of providing culturally sensitive health care service for elders.

Decreased neonatal tibial bone ultrasound velocity in term infants born after breech presentation

OBJECTIVE

Fetuses found to be in the breech presentation have limited motion of their lower limbs. The aim of this study was to test the hypothesis that bone speed of sound (SOS) would be lower in infants born after breech presentation than in those born after vertex presentation.

STUDY DESIGN

We studied 127 singleton, appropriate for gestational age, term infants delivered by a scheduled cesarean delivery at approximately 38 weeks of gestation because of breech presentation or repeat elective cesarean section with vertex presentation. We used the Sunlight Omnisense 7000p device to measure axially transmitted SOS of the right tibia within the first 96 h of life.

RESULT

Fifty-three infants studied (42%) were born by cesarean section after breech presentation compared to 74 vertex controls. Bone SOS was significantly lower in the breech presentation group, even after taking into account the effect of gender and parity (as well as gestational age at birth and birth weight).

CONCLUSION

Bone SOS is lower in infants born after breech presentation than in those born after vertex presentation. We speculate that limited motion of lower limbs in fetuses found to be in the breech presentation leads to a decrease in bone mineralization and strength.

Decreased immune response to hepatitis B eight years after routine vaccination in Israel

BACKGROUND AND AIM

Although immunization of infants against hepatitis B virus (HBV) is the most effective way to prevent infection, duration of the afforded protection is unknown. Titers of anti-HBV antibodies decline with time, especially during the first few years after vaccination. Anti-HBV antibody levels were measured in the serum of vaccinated children in order to determine the duration of the response afforded by the primary course of HBV vaccine.

METHODS

The immunity derived from the HBV vaccine was assessed by measuring antibody levels in 122 healthy children who were vaccinated in a routine vaccination program in Israel.

RESULTS

Ninety-four children (77.1%) had detectable antibodies levels (HBsAb titer > or = 10 mIU/ml): 59 (48.4%) of the children had high antibodies levels (HBsAb titer > 100 mIU/ml). Twenty-eight children (22.9%) had undetectable antibodies levels (HBsAb titer < 10 mIU/ml). When the children were divided into three groups according to the time elapsed since vaccination, it was found that the antibody levels declined with time (p < 0.009). Most of the children with undetectable antibody levels belonged to the 5 to 8-y post-vaccination group (36.1% vs 20% and 14.6% for the 2.5 to 5-y and 1 to 2.5-y groups, respectively, p < 0.01). The mean HBsAb declined in relation to the length of time post-vaccination (226.9 +/- 248.2 mIU/ml for 1-2.5 y post-vaccination, 199.0 +/- 235.7 mIU/ml for 2.5-5 y and 90.4 +/- 138.5 for 5-8 y, p < 0.05). No correlation was found between HBsAb titers and gestational age, birthweight and parental origin, although females generated higher mean antibody levels than males (207.3 +/- 217 mIU/ml vs 141.9 +/- 218.9 mIU/ml, p < 0.05).

CONCLUSION

Our data demonstrate a steady decline in anti-HBV titers over time after routine vaccination against HBV in Israel. The most significant decline occurred 5-8 y post-vaccination.

Prohepcidin concentrations and erythroid progenitors in cord blood of appropriate versus small for gestational age neonates

OBJECTIVE

Prohepcidin (Pro-Hep), synthesized in the liver, is the prohormone of hepcidin (Hep), which reduces iron absorption in the gut; its synthesis is enhanced by inflammation and is reduced during hypoxia. We aimed to study the hypothesis that infants born small for gestational age (SGA) have reduced cord blood concentrations of Pro-Hep.

STUDY DESIGN

Cord blood was collected from 20 SGA (term and near term >35 week gestation) infants and 20 appropriate for gestational age (AGA) controls. We excluded infants exposed to maternal chronic diseases, smoking, diabetes, alcohol or drug use. Both groups had a 1 min Apgar score above or equal to 7 and had normal cord blood pH (above 7.25). ELISA was used to determine serum concentrations of Pro-Hep and erythropoietin (EPO). Circulating CD71(+)/CD45(-)/SSC(low) cells were measured by flow cytometry as an index of erythroid progenitors.

RESULT

There were no significant differences between groups in terms of hemoglobin concentrations, and Pro-Hep. In contrast, EPO levels and circulating CD71(+)/CD45(-)/SSC(low) erythroid progenitors were significantly higher in the SGA group. These differences remained significant even after controlling for gestational age and gravidity.

CONCLUSION

Contrary to EPO upregulation during intrauterine growth restriction (IUGR), and higher concentrations of circulating erythroid progenitors, Pro-Hep concentration is not affected by IUGR.

Marital adjustment and fatherhood

This paper examines the relationship between marital stability and fathers' bonding to their first born infants. Current literature reports on the significant and unique influence of the father on his developing infant and the influence of the father on the mother-infant bond. Some authors suggest that prematurity, the type of delivery, or a father's presence or absence at the birth, influences his engrossment or bonding and later caretaking behaviour. However, little attention has been given to other factors such as the father's personality, education, previous experience with child care or his relationship with his spouse. Similarily, there is a paucity of research on the effect of the birth of the infant on the marital bond. Einzig, Wente and Crockenberg and Dyer suggest that the transition to parenthood is a crisis in the family life and can lead to disruption in the husband-wife relationship. With the apparent increase in family instability in the last decade as marked by the rising divorce rate, it seems crucial to explore what correlation, if any, exists between marital condition and a father's relationship to his newborn infant.

Further assessment of the clinically effective dose range of etoricoxib: a randomized, double-blinded, placebo-controlled trial in rheumatoid arthritis

OBJECTIVE

To further assess the clinically active dose range of etoricoxib, a COX-2 selective inhibitor, in rheumatoid arthritis (RA).

METHODS

RA patients were randomized to etoricoxib 10, 30, 60, or 90 mg or placebo in a double-blind, 12-week study. DMARDs (methotrexate, biologics) or low-dose corticosteroids were allowed in stable doses. The primary endpoint was the proportion of patients completing the study and achieving an American College of Rheumatology 20% (ACR20) response. Secondary endpoints included individual components of the ACR index and Patient Global Assessment of Pain. Safety was assessed by physical exam and adverse experiences (AEs) occurrences.

RESULTS

Etoricoxib 90 mg was the only dose to reach a statistically significant difference from placebo (p < 0.001) on the primary endpoint; etoricoxib 60 mg approached significance (p = 0.057). Significant pain improvement vs. placebo was observed with etoricoxib 90 mg (p < 0.001), 60 mg (p = 0.018), and 30 mg (p = 0.017). Despite the use of background biologics and corticosteroids, a dose response was still apparent. A higher proportion of etoricoxib 60 and 90 mg patients had renovascular AEs (i.e., edema and hypertension) compared with placebo, although discontinuations for renovascular AEs were rare. Etoricoxib 90 mg had a higher incidence of serious AEs (n = 5; 1 was considered drug-related) versus placebo (n = 0).

LIMITATIONS

The present study was not powered to detect differences in cardiovascular or gastrointestinal safety by dose. Additionally, further research is needed to clarify the role of doses less than the etoricoxib 90 mg dose for pain management in RA patients.

CONCLUSION

Etoricoxib 90 mg demonstrated statistically superior efficacy (ACR20) compared with placebo and numerical superiority over the other doses of etoricoxib studied. Etoricoxib 30 and 60 mg demonstrated significant pain improvement versus placebo, suggesting utility for some patients.