Managing treatment fatigue in patients with multiple sclerosis on long-term therapy: the role of multiple sclerosis nurses

Oral delivery of therapeutic proteins by engineered bacterial type zero secretion system

Genetically engineered commensal bacteria are promising living drugs, however, their therapeutic molecules are frequently confined to their colonization sites. Herein, we report an oral protein delivery technology utilizing an engineered bacterial type zero secretion system (T0SS) via outer membrane vesicles (OMVs). We find that OMVs produced in situ by Escherichia coli Nissle 1917 (EcN) can penetrate the intact gut epithelial barrier to enter the circulation and that epithelial transcytosis involves pinocytosis and dynamin-dependent pathways. EcN is engineered to endogenously load various enzymes into OMVs, and the secreted enzyme-loaded OMVs are able to stably catalyze diverse detoxification reactions against digestive fluid and even enter the circulation. Using hyperuricemic mice and uricase delivery as a demonstration, we demonstrate that the therapeutic efficacy of our engineered EcN with a modified T0SS outperforms that with a direct protein secretion apparatus. The enzyme-loaded OMVs also effectively detoxify human serum samples, highlighting the potential for the clinical treatment of metabolic disorders.

Oral Nanomedicine: Challenges and Opportunities

Compared to injection administration, oral administration is free of discomfort, wound infection, and complications and has a higher compliance rate for patients with diverse diseases. However, oral administration reduces the bioavailability of medicines, especially biologics (e.g., peptides, proteins, and antibodies), due to harsh gastrointestinal biological barriers. In this context, the development and prosperity of nanotechnology have helped improve the bioactivity and oral availability of oral medicines. On this basis, first, the biological barriers to oral administration are discussed, and then oral nanomedicine based on organic and inorganic nanomaterials and their biomedical applications in diverse diseases are reviewed. Finally, the challenges and potential opportunities in the future development of oral nanomedicine, which may provide a vital reference for the eventual clinical transformation and standardized production of oral nanomedicine, are put forward.

The role of specialist nurses in detecting spasticity and related symptoms in multiple sclerosis

BACKGROUND

Spasticity is a frequent symptom of multiple sclerosis (MS), which may negatively influence daily living activities (ADL).

OBJECTIVES

To (1) explore the feasibility to conduct a structured interview by specialist nurses about limitations in ADL; (2) determine the percentage of people with MS (PwMS) with limitations in ADL related to spasticity; (3) to assess the knowledge about spasticity and describe its clinical features.

DESIGN

Observational, cross-sectional, multicentre study in 16 MS units of Catalonia (Spain). Participants were recruited from the outpatient facility and day-care hospital between July 2018 and June 2019 and met the following criteria: (1) age 18 or older, (2) diagnosis of MS according to McDonald criteria 2010 and (3) no clinical relapse in previous 30 days.

METHODS

Specialist nurses conducted a structured interview divided in two parts: the assessment of (1) limitations in the ADL and (2) the presence of spasticity and associated symptoms. The usefulness of this intervention was requested. This study met the STROBE reporting guidelines checklist for observational studies.

RESULTS

Three hundred sixty eight pwMS (244 women) with a mean age of 46 years and a median Expanded Disability Status Scale score of 2.5 (range, 0-8.5) were included. 262 (71%) pwMS had limitations in the ADL, and spasticity was reported as the most limiting symptom in 59 (23%). As a result of the interview, spasticity was observed in 199 (76%) participants; 47 (24%) of them were unaware that they had spasticity and 102 (51%) would not have reported it spontaneously. The level of the interview satisfaction was high (90%).

CONCLUSIONS

Spasticity is a complex and limiting symptom in MS. The structured interview conducted by specialist nurses is feasible and has good acceptance.

PATIENT CONTRIBUTION

Specialist nurses can be proactive in MS clinical assessment, which may help to detect symptoms with negative impact on quality of life.

The Development of Cladribine Tablets for the Treatment of Multiple Sclerosis: A Comprehensive Review

Cladribine is a purine nucleoside analog initially developed in the 1970s as a treatment for various blood cancers. Due to the molecule’s ability to preferentially reduce T and B lymphocytes, it has been developed into an oral formulation for the treatment of multiple sclerosis (MS). The unique proposed mechanism of action of cladribine allows for the therapy to be delivered orally over two treatment-week cycles per year, one cycle at the beginning of the first month and one cycle at the beginning of the second month of years 1 and 2, with the potential for no further cladribine treatment required in years 3 and 4. This review summarizes the clinical development program for cladribine tablets in patients with MS, including the efficacy endpoints and results from the 2-year phase III CLARITY study in patients with relapsing–remitting MS (RRMS), the 2-year CLARITY EXTENSION study, and the phase III ORACLE-MS study in patients with a first clinical demyelinating event at risk for developing MS. Efficacy results from the phase II ONWARD study, in which cladribine tablets were administered as an add-on to interferon-β therapy in patients with RRMS, are also summarized. A review of all safety data, including lymphopenia, infections, and malignancies, is provided based on data from all trials in patients with MS, including the initial parenteral formulation studies. Based on these data, cladribine tablets administered at 3.5 mg/kg over 2 years have been approved across the globe for various forms of relapsing MS.

Development of a Conceptual Etiological Model of Treatment Regimen Fatigue Among Patients Engaged in HIV Care: A Qualitative Study

Treatment regimen fatigue (TRF) is a decreased desire and motivation to maintain vigilance in adhering to treatment, and little is known about TRF in people living with HIV. We aimed to develop a conceptual framework of TRF. Five focus groups were conducted in 2014. Eligible participants were (a) HIV infected, (b) at least 18 years of age, (c) prescribed antiretroviral therapy, and (d) fluent in English. Data were analyzed using thematic analysis. Analyses revealed these themes: patient experiences of TRF; etiological factors at the systems, provider, and patient levels; strategies to manage TRF; consequences of TRF; and protective factors that prevent the occurrence of TRF. The results provided a conceptual framework for future investigations to build on in an effort to improve adherence and retention in HIV care. Study results indicate avenues for intervention at multiple levels (systems, provider, and patient) to reduce treatment burden and improve patient resources and capacity.

Exploring meanings of illness causation among those severely affected by multiple sclerosis: a comparative qualitative study of Black Caribbean and White British people

Background

Illness attributions, particularly for those living with life limiting illnesses, are associated with emotional adjustment or psychological distress. Few studies have examined attributions among people severely affected by multiple sclerosis (PwMS), and specifically among from diverse communities. This study aimed to explore and compare the presence and construction of meanings among Black Caribbean and White British PwMS.

Methods

Cross sectional qualitative interviews were conducted among Black Caribbean (BC) and White British (WB) PwMS with an EDSS of ≥6.0 (severe disease). Data were analysed using the framework approach.

Results

15 BC and 15 WB PwMS were interviewed. Attributions were complex with most PwMS reporting multiple explanations. Uncertainty, represents the first theme surrounding the aetiology of MS where participants constantly rehearsed the “why me?” question in relation to their illness, a number expressing considerable frustration. The second theme, ‘logical and scientific’, was voiced more often by WB PwMS and accounts for a range of genetic/viral influences, stress, environmental and lifestyle factors. Third, the ‘supernatural’ illness attribution theme departs from a biomedical perspective and was reported often among BC PwMS. This theme included the sub-categories of tests of faith and divine punishment, a view although exclusive to BC participants but was sometimes in conflict with notions of modernity.

Conclusion

Our findings identify evidence of cross-cultural and intra-group diversity in relation to MS causation. A greater professional awareness of the processes used by PwMS from diverse communities to make sense of their situation will enable health care professionals to facilitate effective support for those in their care and channel relevant psychosocial resources to them. This requires heightened skills in communication and cultural competency.

Initial Validation of the HIV Treatment Regimen Fatigue Scale for Adults Prescribed Antiretroviral Therapy

Clinical observations have linked antiretroviral nonadherence to treatment regimen fatigue in persons living with HIV (PLWH). Although nonadherence appears to be a consequence of treatment regimen fatigue, little is known about the onset, course, and duration of this construct. Our study developed and evaluated psychometric properties of a measure of treatment regimen fatigue for PLWH. Based on a recent review, the concept was hypothesized to reflect decreased motivation, treatment cynicism, and low self-efficacy to adhere to treatment. Items comprising these factors were generated based on measures of similar constructs in the literature. Exploratory factor analyses suggested that a two-factor solution best fit the data and accounted for 35.8% of the variance. Our study supported a two-factor model of treatment regimen fatigue consisting of Treatment Cynicism and Self-Efficacy. The scale provides a new tool to assess treatment regimen fatigue in PLWH and can be used to inform and improve treatment of HIV.