A double-blind, randomized, placebo-controlled study of fentanyl buccal tablet (FBT) in opioid-tolerant patients with chronic cancer pain and breakthrough pain

9057

Background: Episodes of cancer-related breakthrough pain (BTP) often peak in intensity in minutes. Pain relief with traditional, short-acting oral opioids is often not achieved for =30 min. Fentanyl buccal tablet (FBT) has a rapid onset of analgesia. This double- blind, randomized, placebo-controlled study evaluated the efficacy and safety of FBT in opioid-tolerant patients with cancer and BTP. Methods: After open-label titration to establish a successful dose of FBT, patients were randomized to prespecified, double-blinded sequences of 10 tablets (7 FBT, 3 placebo). Pain intensity (PI) was assessed from 5 to 120 min post dose. The primary efficacy measure was the sum of PI differences (PIDs) for the first 60 min (SPID60); secondary measures included PIDs, =33% and =50% improvements in PI, and global medication performance (GMP). Use of supplemental BTP medication and adverse events (AEs) were reported. Results: 129 patients were enrolled; 87/125 treated (70%) identified an effective FBT dose and entered the double-blind phase. SPID60 significantly favored FBT vs placebo (mean±SEM, 9.7±0.63 vs 4.9±0.50; p<0.0001). PID differed significantly vs placebo at 10 min (mean±SEM, 0.9±0.09 vs 0.5±0.09; p<0.0001) and at all time points through 2 hr (p<0.0001). Improvements in PI of =33% and =50% from baseline occurred in a larger proportion of episodes following FBT vs placebo from 10 min (16% vs 10% and 7% vs 4%, respectively; p<0.05) through 2 hr (74% vs 38% and 66% vs 28%; p<0.0001). Ratings of GMP were superior for FBT vs placebo at 60 and 120 min (p<0.0001). Supplemental opioids were required for approximately 3 times more BTP episodes following placebo compared with FBT. AEs were typical for opioids, e.g. nausea (13%), dizziness (11%), fatigue (8%), and constipation (6%). Application site-related AEs occurred in 12 patients (10%). A total of 11/125 (9%) patients had =1 serious AE; these were considered not/unlikely to be related to study drug. Conclusions: FBT was effective and well tolerated in the management of BTP in opioid-tolerant patients with cancer-related pain, with an early onset of analgesia and a sustained duration of effect.

No significant financial relationships to disclose.

Efficacy and tolerability of fentanyl buccal tablet (FBT) in opioid-tolerant cancer patients with neuropathic pain

19549

Background: Fentanyl buccal tablet (FBT), a new formulation recently approved by the FDA for opioid-tolerant patients with cancer-related breakthrough pain (BTP), provides rapid-onset analgesia. Neuropathic pain is the primary pain pathophysiology in a significant proportion of patients with chronic cancer pain; therefore, the efficacy and safety of FBT was studied in this subpopulation. Methods: The efficacy and safety of FBT in the treatment of BTP in opioid-tolerant cancer patients with neuropathic pain were evaluated as a sub-analysis of two randomized, double-blind, placebo-controlled studies. Of the 45 patients in the sub-analysis (50% male, 86% white, mean age 56 years), 30 identified an effective FBT dose during open-label titration and were randomly assigned to double-blind crossover dose sequences of 10 tablets (7 FBT, 3 placebo). Pain intensity (PI) and pain relief (PR) were recorded at intervals after dosing. The primary efficacy measures were the sum of pain intensity differences (PIDs) for the first 30 (SPID30) and 60 minutes (SPID60); secondary efficacy measures included PIDs, PR, and total pain relief (TOTPAR). Use of supplemental BTP medication and adverse events (AEs) were recorded. Results: Combined data (all values mean ±SD) favored FBT vs placebo for SPID30 (3.35±3.11 vs 1.88±2.58) and were significant for SPID60 (9.90±7.19 vs 5.51±6.06; 95% CI, 2.99, 5.81). There was a greater reduction in PI following FBT vs placebo at 10 minutes (PID, 0.55±0.89 vs 0.24±0.48), which continued through observation periods of up to 2 hours (3.43±2.44 vs 1.95±1.99). Higher PR scores were noted following FBT vs placebo at 10 minutes (0.43±0.39 vs 0.21±0.28), which continued for up to 2 hours (1.99±0.72 vs 1.36±0.60). TOTPAR was better following FBT vs placebo at 15 (0.88±0.89 vs 0.48±0.73), 30 (2.42±1.85 vs 1.40±1.65), 45 (4.29±2.90 vs 2.61±2.68), and 60 minutes (6.34±4.02 vs 3.94±3.81). Patients were more than twice as likely to require supplemental opioids for BTP episodes following placebo vs FBT. AEs were typical for opioids; e.g., headache (23%), nausea (18%), dizziness (18%), vomiting (14%), and fatigue (11%). Conclusions: FBT was effective and well tolerated in a subgroup of cancer patients with BTP in association with chronic neuropathic pain.

No significant financial relationships to disclose.

Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Lequesne Algofunctional Index of knee in Asians with knee osteoarthritis in Singapore

OBJECTIVE

To cross-culturally adapt and validate Singapore English and Chinese versions of the Lequesne Algofunctional Index of knee in patients with knee osteoarthritis (OA) in Singapore.

METHODS

Singapore English and Chinese versions were cross-culturally adapted from the source English version following standard guideline (including cognitive debriefing). Patients were asked to complete an identical, pretested questionnaire containing the Lequesne index, Short Form 36 Health Survey (SF-36), and EQ-5D twice within 6 days. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients (ICC). Dimensionality was assessed by principal component factor analysis. Construct validity was tested by item-to-scale correlations and 12 and six a priori hypotheses for convergent and divergent construct validities, respectively.

RESULTS

Singapore English and Chinese Lequesne indices were well accepted by patients in pilot testing and were therefore administered to a consecutive sample of 127 English- and 131 Chinese-speaking Singaporeans with knee OA. Acceptable internal consistency was observed for activities of daily living and the global index (alpha=0.72-0.82), and the good test-retest reliability for all scales in both versions (ICC=0.66-0.94). Expected item-to-scale correlations were presented only in activities of daily living in both versions. Factor analysis yielded two factors for both versions. Convergent and divergent construct validities were supported by the presence of hypothesized correlations between the Lequesne index and SF-36 and EQ-5D scales.

CONCLUSION

Both versions of the Lequesne index demonstrated acceptable reliability and validity among multiethnic Asian patients with knee OA, which suggests that it could be used as a global index in the health-related quality of life (HRQoL) measurements in Singapore and possibly other Asian countries.

Identification of three FGA mutations in two Chinese families with congenital afibrinogenaemia

Congenital afibrinogenaemia is a rare autosomal recessive disorder, characterized by the complete absence or extremely reduced level of fibrinogen (Fg). We attempted to analyse the phenotype and genotype in two Chinese families with congenital afibrinogenaemia. Coagulation studies including activated partial thromboplastin time (APTT), prothrombin time (PT) and thrombin time (TT) and Fg were performed in the patients and other family members. All the exons, exon-intron boundaries and promoter regions of three Fg genes (FGA, FGB and FGG) were screened by direct sequencing. Three patients in two families suffered from moderate to severe haemorrhage. Their APTT, PT and TT were extremely prolonged and plasma Fg levels were undetectable by Clauss method and extremely reduced by immunoassay. Genetic analysis revealed three FGA mutations in three patients including one novel mutation. In family 1, patient 1 was detected compound heterozygous mutations in FGA, g.1892-1899delAGTA/GTAA from her patriline and g.1978-g.3215del1238 bp from her matriline. In family 2, a homozygous Gln203X in Aalpha-chain was found in both patients 2 and 3 due to consanguineous marriage. All these mutations were null mutations, which could produce premature stop codons in FGA. It can be indicated that with more genetic analysis performed on afibrinogenaemia patients all over the world, there is no distinct difference in geographical distribution of Fg gene mutations. Gln203X in Aalpha-chain was first reported in this study, which may help to further understand the function of Aalpha-chain.

Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) in Asians with knee osteoarthritis in Singapore

OBJECTIVE

To cross-culturally adapt and validate Singapore English and Chinese versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients with knee osteoarthritis (OA) in Singapore.

METHODS

Singapore English and Chinese versions were cross-culturally adapted from the source English KOOS following standard guidelines (including cognitive debriefing). Patients were asked to complete identical questionnaires containing the KOOS, Short Form 36 Health Survey, and EQ-5D twice within 6 days. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients (ICC), dimensionality using item-to-domain correlations and convergent and divergent construct validity using 14 and 13 a priori hypotheses, respectively.

RESULTS

Singapore English and Chinese KOOS versions were well accepted by patients in pilot testing and were therefore administered to a consecutive sample of 127 English and 131 Chinese-speaking Singaporeans with knee OA. Cronbach's alpha exceeded 0.7 for all domains except for Chinese pain and symptoms domains. ICC exceeded 0.7 for all domains except for English sport and recreation and Chinese knee-related QoL domains. Hypothesized item-to-domain correlations (Spearman's rho>or=0.4) were observed for 38 items in English and 29 in Chinese versions. Convergent construct validity was supported by the presence of hypothesized moderate/strong correlations (rho=0.37-0.65) for 13 and 11 a priori hypotheses in the English and Chinese KOOS, respectively. Divergent construct validity was supported by the presence of weak correlations (rho=0.02-0.34) for 12 and 11 a priori hypotheses in the English and Chinese KOOS, respectively.

CONCLUSION

The Singapore English and Chinese KOOS were well accepted and demonstrated acceptable reliability and validity in Asian patients with knee OA in Singapore.

The K2 2(3)Pi(g) state: new observations and analysis

Totally 3045 transitions into the 2(3)Pi(g) v = 0-42, J = 0-103, Omega = 0, 1, 2 rovibrational levels have been observed by infrared-infrared double resonance fluorescence excitation and two-photon spectroscopy. Molecular constants including the spin-orbit interaction parameters are obtained. Although the K2 2(3)Pi(g) state dissociates to the 4s + 3d atomic limit, it is strongly mixed with the 3P ionic states in the range of the potential well. This mixing results in a relatively large equilibrium internuclear distance Re = 5.254 A and a larger spin-orbit constant A0 approximately 14.17 cm(-1) than that of the atomic limit -2.33 cm(-1). Strong perturbations of the 2(3)Pi(g) levels observed are attributed to the spin-orbit coupling with the 4(1)Sigma(g)+ state.

Female hemophilia A heterozygous for a de novo frameshift and a novel missense mutation of factor VIII

BACKGROUND

Hemophilia A (HA) is an X-chromosome-linked recessive disorder.

AIM

We report the case of a female HA patient with a moderate decrease of factor (F) VIII activity and antigen (FVIII:C 3.4%, FVIII:Ag 4.2%) and severe bleeding symptoms.

METHODS

The patient's father had mild FVIII deficiency (FVIII:C 6.9%, FVIII:Ag 7.4%), and her mother had normal FVIII activity. The von Willebrand disease antigen and von Willebrand factor ristocetin cofactor activity were normal in all family members. The genomic DNA was extracted from the peripheral blood lymphocytes of the patient and her family members. Long-distance polymerase chain reaction (PCR) was employed to screen for the intron 22 inversion of the FVIII coding gene (F8). The F8 coding sequence was amplified with PCR and sequenced with an automatic sequencer.

RESULTS

Two heterozygous mutations were identified in the patient: one a substitution of nucleotide 5981T by C that leads to a missense mutation Leu1975Pro, and the other an insertion of an 'A' between nucleotides 3,637 and 3,638 (3637_3638insA) that shifts the reading frame and predicts a premature stop codon downward. The mutation Leu1975Pro was identified in the father's F8; however, 3637_3638insA was a de novo mutation that occurred in the patient's maternal-derived F8. Real-time PCR was applied to analyze the level of ectopically F8 gene transcripts in the peripheral lymphocytes of family members. The ectopic transcripts of F8 of the patient were less abundant than the normal control (patient:normal control ratio 0.67), whereas her parents showed no significant difference from the normal control.

CONCLUSION

The FVIII deficiency of the HA patient resulted from a de novo occurrence of a frameshift 3637_3638insA in her maternal-derived F8 and a novel missense mutation Leu1975Pro inherited from her father.

Are they relevant? A critical evaluation of the international classification of functioning, disability, and health core sets for osteoarthritis from the perspective of patients with knee osteoarthritis in Singapore

OBJECTIVES

To determine the extent to which health items identified from the perspective of patients with knee osteoarthritis can be linked with the International Classification of Functioning, Disability and Health (ICF); and to evaluate critically the content validity of ICF comprehensive and brief core sets for osteoarthritis.

METHODS

Items identified from a focus group study were linked independently by two researchers based on the 10 a priori linking rules. Both percentage agreement and kappa statistics were calculated to measure interobserver agreement. Any disagreements were resolved by reaching a consensus among the researchers. The categories linked with all items were compared with the comprehensive core set, while the categories linked with those items reported as important by over 30% of subjects within each of three local ethnic groups (Chinese, Malay, and Indian) were compared with the brief core set. Both comparisons were made only at the second level of the ICF.

RESULTS

In all, 74 items were linked with 44 different ICF categories through 105 linkages with generally good interobserver agreement. The 69 items were linked with the ICF at the third or fourth levels. Both commonalities and disparities were found through comparison between the categories linked with these items and both core sets.

CONCLUSIONS

All items could be successfully linked with the ICF. The comprehensive core set showed good content validity, while the brief core set needs to be supported by more empirical evidence in various sociocultural contexts. This study specifically complemented the development and refinement of both core sets from the perspective of patients with knee osteoarthritis.

Management of abnormal uterine hemorrhage with atypical endometrial hyperplasia by transcervical resection of endometrium

The aim of the study was to assess the feasibility and effect of treating atypical endometrial hyperplasia (AEH) with transcervical resection of endometrium (TCRE). Five cases of AEH incapable of hysterectomy for various reasons were treated with TCRE. All patients were followed up for 3-4 years postoperation to evaluate the thickness of endometrium, uterine cavity, and prognosis of the disease. All the patients provided informed consent for TCRE. In all five cases treated with TCRE, case 1 was for senility, hypertension, diabetes mellitus, and obesity; case 4 for senility, obsolete cerebral infarction, and hemiplegia; case 5 for uremia and chronic dysfunction of coagulation after renal transplantation; cases 2 and 3 for rejection of hysterectomy. All cases were followed up for more than 3 years after operation. Four had amenorrhea and one had dropping menses. The thickness of endometrium was no more than 5 mm in all the cases. TCRE is one available microinvasive surgery alternative to hysterectomy for AEH patients contraindicated to hysterectomy.

Evaluation of restenosis and extent of coronary artery disease in patients with previous percutaneous coronary interventions by dobutamine stress real-time myocardial contrast perfusion imaging

OBJECTIVES

To assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) for the diagnosis of restenosis and extent of coronary artery disease (CAD) in patients with previous percutaneous coronary intervention (PCI).

METHODS

56 patients were studied 1.9 (SD 1.4) years after PCI. They underwent MCPI with commercially available ultrasound contrast agents (Optison or Definity) at rest and at peak dobutamine-atropine stress. Coronary angiography was performed within one month. Significant CAD was defined as >or= 50% stenosis in >or= 1 major epicardial coronary artery. Significant restenosis was defined as >or= 50% stenosis in a coronary segment with previous intervention.

RESULTS

Reversible perfusion abnormalities were detected in 40 of 43 patients with significant CAD and in 4 of 13 patients without (overall sensitivity 93%, 95% CI 85% to 99%; specificity 69%, 95% CI 44% to 94%; and accuracy 88%, 95% CI 79% to 96%). Significant restenosis in >or= 1 coronary artery with previous PCI was detected in 38 (68%) patients. Reversible perfusion abnormalities were present in 35 of them (sensitivity 92%, 95% CI 84% to 99%). Reversible perfusion abnormalities were detected in >or= 2 vascular distributions in 20 of 28 patients with multivessel CAD and in 3 of 28 patients without (sensitivity 71%, 95% CI 55% to 88%; specificity 89%, 95% CI 78% to 99%; and accuracy 80%, 95% CI 70% to 91%). Restenosis was detected in 41 coronary arteries. Sensitivity of MCPI for regional diagnosis of restenosis was 73% (95% CI 60% to 87%), specificity was 75% (95% CI 60% to 90%), and accuracy was 74% (95% CI 64% to 84%).

CONCLUSION

Dobutamine stress MCPI is a useful technique for the evaluation of restenosis and extent of CAD after PCI.

Characterization and application of two novel monoclonal antibodies against human OX40: costimulation of T cells and expression on tumor as well as normal gland tissues

OX40, a membrane-bound molecule of the tumor-necrosis-factor-receptor superfamily, is a critical costimulatory receptor during the immune response. Here, we newly generated two specific mouse antihuman OX40 monoclonal antibodies (mAbs) (2G2 and 1F7), whose specificities are quite different from the available OX40 mAb (ACT35) by competition assay. It was also found that both mAbs could enhance the proliferation, activation and differentiation of T lymphocytes primed by anti-CD3 mAb. These results evidenced that both were functional antihuman OX40 mAbs. Furthermore, stained by 2G2 and 1F7, FCM and immunohistochemistry detected the constitutive expression of OX40 on tumor cell lines from epithelium, breast cancer and glioma tissues. Meanwhile, the non-tumor tissues (thyroid gland, stomach gland) were also found OX40 expression. These results suggested that OX40 is not only expressed in activated T cells, but also in some tumors as well as normal gland tissues. Such expression pattern indicated that OX40 may be a valuable surface antigen in unveiling its expression and function outside the immune system. Briefly, these novel antibodies may contribute to the evaluation of the mechanism of tumor metastasis and eventually shed light on further study of tumor immunotherapy and autoimmune diseases.

What health domains and items are important to patients with knee osteoarthritis? A focus group study in a multiethnic urban Asian population

OBJECTIVES

To determine important health-related quality of life (HRQoL) domains and items within each domain affected by knee osteoarthritis (OA), identify ethnic variations in the importance of these domains and items among three ethnic groups, and determine how identified domains and items mapped onto selected OA-specific HRQoL instruments.

METHODS

Focus groups were conducted among subjects with knee OA stratified by gender, ethnicity, and language spoken. All focus groups were audio-taped and transcribed verbatim, with subsequent translation into English for groups conducted in other languages. Data analysis was performed by combining the key elements of grounded theory and content analysis with the assistance of the qualitative software ATLAS/ti 5.0.

RESULTS

Five domains (pain, physical disability, other symptoms of OA, mental health, and social health) were identified from the 74 items reported as important by at least one subject. These domains were important for subjects from all ethnic groups with the exception of social health, which was more often important for Malay subjects. Items more commonly reported as important in the pain, physical disability, and other symptoms of OA domains were generally similar across ethnic groups. In contrast, important items in the mental and social health domains differed among ethnic groups.

CONCLUSIONS

The impact of knee OA on HRQoL is broadly similar in both Asian and Western socio-cultural contexts. Both similarities and differences in important domains and items were identified among subjects with knee OA from three major Asian ethnic groups.

Management of abnormal uterine hemorrhage with atypical endometrial hyperplasia by transcervical resection of endometrium

The aim of the study was to assess the feasibility and effect of treating atypical endometrial hyperplasia (AEH) with transcervical resection of endometrium (TCRE). Five cases of AEH incapable of hysterectomy for various reasons were treated with TCRE. All patients were followed up for 3–4 years postoperation to evaluate the thickness of endometrium, uterine cavity, and prognosis of the disease. All the patients provided informed consent for TCRE. In all five cases treated with TCRE, case 1 was for senility, hypertension, diabetes mellitus, and obesity; case 4 for senility, obsolete cerebral infarction, and hemiplegia; case 5 for uremia and chronic dysfunction of coagulation after renal transplantation; cases 2 and 3 for rejection of hysterectomy. All cases were followed up for more than 3 years after operation. Four had amenorrhea and one had dropping menses. The thickness of endometrium was no more than 5 mm in all the cases. TCRE is one available microinvasive surgery alternative to hysterectomy for AEH patients contraindicated to hysterectomy.

Are they being used safely? A retrospective cross-sectional tertiary health care survey of selective serotonin reuptake inhibitors prescribing practice in Singapore

OBJECTIVES

To determine the prescribing pattern of the SSRIs and to evaluate the safety of current utilization of SSRIs associated with concomitant psychotropic medications in Singapore.

METHODS

The average prescribed daily dose (PDD) for each SSRI was calculated and compared with the defined daily dose (DDD). Pearson's chi2 test, one-way analysis of covariance (ANCOVA) and multinomial logistic regression were performed to examine the impacts of variables such as age, gender, patient type and concomitant psychotropic medications on the utilization of SSRIs. Safety issues were discussed by examining the potential metabolic drug interactions between the SSRIs and concomitant psychotropic medications.

RESULTS

The most frequently prescribed SSRI was fluoxetine and the PDDs were slightly more than the DDDs for all these SSRIs except fluvoxamine. The SSRIs were mainly prescribed to the patients who were younger, female and outpatients. Psychotropics were more likely concomitantly used with fluvoxamine, sertraline and paroxetine, relative to fluoxetine.

CONCLUSION

The prescribing pattern of SSRIs in a tertiary health center in Singapore is generally consistent with the accepted practices, although some safety concerns in terms of metabolic drug interactions were raised. This study provides useful baseline information for further in-depth studies for SSRIs usage both locally and for international comparison.

Characterization and application of two novel monoclonal antibodies against 2IgB7-H3: expression analysis of 2IgB7-H3 on dendritic cells and tumor cells

2IgB7-H3 has recently been identified as a new member of the B7 family. Its expression at the protein level remains largely unknown due to the lack of the specific monoclonal antibody (mAb). To characterize the expression of 2IgB7-H3, we newly generated two mouse antihuman 2IgB7-H3 mAbs (4H7 and 21D4). We found the constitutive expression of 2IgB7-H3 on a series of tumor cell lines. Furthermore, the expression was examined on monocyte-derived dendritic cells (Mo-DCs) and DCs from CD34(+) hematopoietic progenitor cells (HPC) by means of mAb staining. The results showed that 2IgB7-H3 was expressed on Mo-DCs at a high and stable level during differentiation in vitro. With the maturation of DCs from CD34(+) HPCs, the expression of the molecule was upregulated. However, the 2IgB7-H3 was not expressed on fresh isolated T and B lymphocytes, monocytes, or CD34(+) HPCs. These results suggested that 2IgB7-H3 may be a valuable surface antigen for the detection of DCs.

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-c30): validation of English version in Singapore

OBJECTIVE

This study aimed to validate the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, English version 3.0) in Singaporean cancer patients.

METHODS

In a cross-sectional study, a heterogeneous sample of cancer patients (n = 57) self-administered a questionnaire containing the QLQ-C30, the Short Form 36 Health Survey (SF-36) and assessing health and sociodemographic status. Construct validity was assessed by testing a priori hypotheses that QLQ-C30 scales would be moderately or strongly correlated with SF-36 scales measuring similar dimensions of health-related quality of life (HRQoL) and that subjects reporting mild symptoms would have better HRQoL scores than those reporting severe symptoms. Internal consistency reliability was assessed using Cronbach's alpha.

RESULTS

Strength of Spearman's correlations between the QLQ-C30 and SF-36 scales assessing similar dimensions of HRQoL ranged from 0.35 to 0.67. Subjects with mild symptoms had better scores than those with severe symptoms for all six QLQ-C30 HRQoL scales (p < 0.05 for five scales, Mann-Whitney U tests). Cronbach's alpha ranged from 0.19 for the cognitive functioning scale to 0.91 for the global QoL scale.

CONCLUSION

This study provides preliminary evidence for the validity and reliability of the EORTC QLQ-C30 in English-speaking Singaporean cancer patients.