Analysis of Clinical Trial Screen Failures in Inflammatory Bowel Diseases [IBD]: Real World Results from the International Organization for the study of IBD

BACKGROUND

Recruitment for randomized controlled trials [RCTs] in inflammatory bowel diseases [IBD] has substantially dropped over time. This study aimed to assess reasons why IBD patients are not included in sponsored multicentre phase IIb-III RCTs.

METHODS

All IOIBD members [n = 58] were invited to participate. We divided barriers to participation as follows: [1] reasons patients with active IBD were not deemed appropriate for an RCT; [2] reasons qualified patients did not wish to participate; and [3] reasons for screen failure [SF] in patients agreeing to participate. We assess these in a 4-week prospective study including, consecutively, all patients with symptomatic disease for whom a treatment change was required. In addition, we performed a 6-month retrospective study to further evaluate reasons for SF.

RESULTS

A total of 106 patients (60 male [56.6%], 63 Crohn's disease [CD] [59.4%]), from ten centres across the world, were included in the prospective study. An RCT has not been proposed to 65 of them [mainly due to eligibility criteria]. Of the 41 patients to whom an RCT was offered, eight refused [mainly due to reluctance to receive placebo] and 28 agreed to participate. Among these 28 patients, five failed their screening and 23 were finally included in an RCT. A total of 107 patients (61 male [57%], 67 CD [62.6%]), from 13 centres worldwide, were included in our retrospective study of SFs. The main reason was insufficient disease activity.

CONCLUSION

This first multicentre study analysing reasons for non-enrolment in IBD RCTs shows that we lose patients at each step. Eligibility criteria, the risk of placebo assignment, and insufficient disease activity were part of the main barriers.

Treat-to-Target: The Era of Targeted Immunosuppressive Agents in IBD Management

With the advent of biologic agents, the treatment of patients with Inflammatory Bowel Diseases (IBD) has changed from managing symptoms to achieving remission of disease. Disease remission is associated with better outcomes than symptomatic care alone. The Treat-to-Target paradigm provides targets that serve as surrogates for achieving disease remission. The most important target is endoscopic mucosal healing and other targets include symptomatic response, symptomatic remission, biomarker normalization, and normalization of patient's quality of life. Targets are reached via utilization of biologic medications that may be modified or substituted as goals are not met. IBD Qorus represents a national collaborative of academic IBD centers and private gastroenterology practices using the Treat-to-Target approach and patient-centered communication methods to provide better care for all patient's suffering from IBD.

Hyperbaric Oxygen as Successful Monotherapy for a Severe Ulcerative Colitis Flare

This report presents a case of severe ulcerative colitis treated with hyperbaric oxygen as successful monotherapy.

Application of reflectance spectroscopy to identify maize genotypes and aflatoxin levels in single kernels

Spectroscopy is a rapid, non-destructive, and low-cost analytical technique that has the potential to complement more resource-intensive analytical methods. We explored the use of spectral methods to differentiate maize genotypes and assess aflatoxin (AF) contamination in maize kernels. We compared the performance of two instruments: a research-grade ultraviolet-visible-near infrared (UV-Vis-NIR) spectrometer that measures reflectance from 304 -1,085 nm, and a miniaturised NIR spectrometer that measures reflectance from 740-1,070 nm. Both systems were used to predict AF levels in maize kernels from a single genotype and across 10 genotypes, and to predict genotype for the latter. A partial least square discriminant analysis model was trained on 70% of the kernels and tested on the remaining 30%. The classification accuracy for 10 maize genotypes was 71-72% using the UV-Vis-NIR instrument on 1,170 kernels, and 65-66% using the NIR device on 740 kernels. The classification accuracy for 247 AF-contaminated kernels of a single genotype using the UV-Vis-NIR instrument was 71, 82, and 92% for AF thresholds of 20, 100, and 1000 μg/kg, respectively. Using the same spectrometer on 872 kernels from 10 genotypes, AF classification accuracy was 67, 90, and 95% in validation sets for AF thresholds of 20, 100, and 1000 μg/kg, respectively. The UV-Vis-NIR instrument and the NIR device had similar classification accuracies for AF thresholds of 100 and 1000 μg/kg, whereas the NIR device had higher accuracy for the AF threshold of 20 μg/kg. Reflectance spectroscopy outperformed visual sorting and the bright greenish yellow fluorescence test in identifying AF levels. Applying spectral analysis to estimate mycotoxin levels and to identify maize genotypes could contribute to regional toxin surveillance and action efforts. Further, using AF-associated spectral features for grain sorting can reduce AF exposure.

AB0556 CHARACTERISTICS OF PATIENTS DIAGNOSED WITH UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE

Background

Patients with undifferentiated connective tissue disease (UCTD) struggle with physical symptoms as well as diagnostic uncertainty.1 UCTD diagnosis requires exclusion of other connective tissue diseases (CTD). Prior studies use variable definitions of UCTD that do not account for updated classification criteria thus limiting generalizability.

Objectives

We identified characteristics associated with rheumatologist-diagnosed UCTD, applied strict exclusion criteria, and compared UCTD patients to those with criteria-defined CTD.

Methods

We recruited patients ≥18 years old seen between 2018-2022 who had rheumatologist-diagnosed UCTD with positive ANA and ≥1 sign/symptom of a CTD. We reviewed medical records to identify those who fulfilled ACR/EULAR-endorsed classification criteria for SLE, RA, SSc, Primary Sjögren’s, Idiopathic Inflammatory Myopathy, and 2006 Revised Sapporo Criteria for APS. We compared sociodemographic, clinical, serologic, and treatment variables between UCTD and CTD using chi-square, Fisher’s exact, and t-tests.

Results

Of 89 patients with rheumatologist-diagnosed UCTD (mean age 49.0 ± 13.7 years, 97.8% female, 66.3% White), 59 (66.3%) had UCTD and 30 (33.7%) had criteria-defined CTD (27 SLE, 3 SLE and RA, 1 RA, and 1 APS).

Patients in both groups had similar non-criteria manifestations, most commonly arthralgia (89.8% UCTD vs. 83.3% CTD, p=0.50) and fatigue (55.9% UCTD vs. 73.3% CTD, p=0.17). Compared to patients with CTD, those with UCTD were less likely to have nonerosive arthritis (27.1% vs. 56.7%, p=0.01) (Table 1).

Table 1.

Characteristics of Patients with UCTD or Criteria-Defined CTD

UCTD1 (n=57), N (%)CTD2 (n=32), N (%)p-valuesClinical3,4•,4nicalN (%))cs of Pa16 (27.1)17 (56.7)0.01•.0156.7) (%))cs of Patients with UCTD or Criteria31 (52.5)18 (60.0)0.65•.6560.0) (%))cs of Patient7 (11.9)4 (13.3)1.0•.013.3)) (%))cs of Patients with UCTD or Criteria-Defined C27 (45.8)14 (46.7)1.0•.0(46.7) (%))cs of Patien24 (40.7)11 (36.7)0.82Serology3•erology) (%))cs of Patients with UCTD or Criteria-Defined CTDth19 (32.2)19 (63.3)<0.01•0.013.3) (%))cs of Patien9 (15.3)13 (4.3)<0.01•0.01.3)) (%))22 (37.3)25 (83.3)<0.01•0.013.3) (%))cs of Patients w10 (16.9)6 (20.0))0.77•.770.0)) (%))cs of Patients with UCTD or Criteria-D6 (10.2)2 (6.7)0.71•.71.7))) (%))cs of Patients with UCTD or Criteria-Defined CTDther CTDs. Our fi18 (30.5)10 (33.3)0.81•.8133.3) (%))cs11 (18.6)6 (20.0)1.0

1. Do not fulfill ACR/EULAR classification criteria for SLE, RA, SSc, PSS, IIM, APS.

2. Diagnosed with UCTD and fulfill ≥1 set of listed CTD classification criteria.

3. Defined per listed classification criteria

4. Criteria with n≤5: fever, proteinuria/cellular casts, pulmonary hypertension, interstitial lung disease, dysphagia/esophageal dysmotility

Patients with UCTD were less likely than those with CTD to have any hematologic manifestation (lymphopenia, leukopenia, thrombocytopenia, or hemolytic anemia) (p=0.02), anti-dsDNA or anti-Smith antibodies (p<0.01), or hypocomplementemia (p<0.01). The frequency of RA, Sjogren’s, and APS-related serologies did not differ between groups (Table 1).

Compared to those with CTD, UCTD patients were less likely to have ever received systemic corticosteroids (71.2% vs. 96.7%, p<0.01); ever use of any disease-modifying antirheumatic drug (DMARD) was similar (35.6% vs. 46.7%, p=0.36).

Conclusion

Among patients diagnosed with UCTD, 66.3% met a stringent definition. Compared to those with criteria-defined CTD, UCTD patients had lower frequency of arthritis, hematologic abnormalities, SLE-specific antibodies, and hypocomplementemia. While use of DMARDs did not differ, UCTD patients were less likely to use systemic corticosteroids.

Rheumatologists diagnose UCTD even when criteria are met for other CTDs. Our findings suggest UCTD is nonetheless a distinct clinical entity; more rigorous characterization will enable generalizable prognostic and therapy trials.

References

[1]Siegel CH, et al. J Clin Rheumatol 2021 Mar 5. doi: 0.1097/RHU. 0000000000001714

Disclosure of Interests

None declared

AB1388 CHARACTERISTICS ASSOCIATED WITH MYCHART ACTIVATION AND REASONS FOR NON-USE AMONG RHEUMATOLOGY CLINIC PATIENTS

Background

Electronic patient portals, such as MyChart by Epic, allow patients to view their medical records, request medication refills, and communicate with their health care providers. Factors associated with portal use include being younger, female, White, having private insurance, and having chronic illness.1

The Hospital for Special Surgery (HSS) rheumatology clinic serves primarily patients with public insurance (Medicaid, which insures low-income adults, and Medicare, which insures adults >65 years old and those with eligible chronic illness/disability). These patients may be at increased risk for poor health outcomes due to clinical and socioeconomic factors and they are less likely to use MyChart than patients seen in HSS private practices. Increased MyChart use may benefit this high-risk group and improve health equity.

Objectives

This study aims to identify characteristics associated with MyChart activation and reasons for its underutilization among patients seen in the HSS rheumatology clinic.

Methods

We identified all patients aged ≥ 18 years seen in the HSS rheumatology clinic at least twice between January 15, 2019 and January 14, 2021, with at least one visit occurring between July 15, 2020 and January 14, 2021. MyChart status (active vs. inactive) and sociodemographic and clinical variables were extracted from the electronic health record (EHR). We used chi-square tests and t-tests to compare characteristics between patients with and without active MyChart; p-value <0.05 was considered significant (Table 1). In addition, 10 rheumatology fellows were prompted on 3 occasions over 6 weeks to informally survey their own clinic patients with inactive MyChart accounts by asking: “What is your primary reason for not using MyChart?”.

Table 1.

Baseline Characteristics of Hospital for Special Surgery Rheumatology Clinic Patients Stratified by MyChart Activation Status

MyChart Active (N=726)MyChart Inactive (N=501)p-valueAge, yrs - Mean (SD)50.3 (15.6)60.0 (15.3)<0.01Female - N (%)601 (82.8)412 (82.2)0.80Race - N (%)0.37•White/Caucasian275 (37.9)184 (36.7)•Black/African American185 (25.5)135 (27.0)•Asian58 (8.0)25 (5.0)•Other189 (26.0)145 (28.9)•Unknown18 (2.5)11 (2.2)Ethnicity - N (%)0.27•Hispanic/Latino294 (40.5)226 (45.1)•Not Hispanic/Latino422 (58.1)268 (53.5)•Unknown10 (1.4)7 (1.4)Preferred language - N (%)<0.01•English611 (84.2)332 (66.3)•Spanish72 (9.9)134 (26.8)•Other43 (5.9)35 (7.0)Needs interpreter - N (%)106 (14.6)156 (31.1)<0.01

Results

There were 1,227 patients included (93.2% with Medicaid and/or Medicare insurance). Compared to patients with inactive MyChart (42.9%), those with active MyChart (57.1%) were younger (50.3 ± 15.6 vs. 60.0 ± 15.3 years, p<0.01). The majority of patients in both groups was female. There was no significant difference in race or ethnicity between groups. Patients without active MyChart were less likely to identify English as their preferred language and more likely to require an interpreter for clinic visits (Table 1).

The rheumatology fellows collectively asked 16 clinic patients with inactive MyChart their primary reason for non-use. The most commonly cited reason was difficulty using the technology (n=8; 50.0%); others included visual impairment (n=2; 12.5%), preference for using the telephone (n=2; 12.5%), concerns about security/spam (n=2; 12.5%), not having a smart phone/computer (n=1; 6.3%), and having a language barrier (n=1; 6.3%).

Conclusion

In the HSS rheumatology clinic, patients who did not have active MyChart were older and less likely to be English-speaking than those who did. The most common barrier to MyChart use reported by patients was difficulty with the technology. This pilot data suggests a need for interventions to facilitate patient-provider communication, specifically targeting older and non-English-speaking rheumatology clinic patients, with the goal of advancing patient engagement and health equity.

References

[1]Ancker JS, et al. J Gen Intern Med. 2011 June 7. doi: 10.1007/s11606-011-1749-y.

Disclosure of Interests

Caroline Siegel: None declared, Anne Bass: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Walgreens, Cytodyn, Omar Bruce: None declared, Justin Olmscheid: None declared, Nilasha Ghosh: None declared, Sebastian E. Sattui Grant/research support from: AstraZeneca, Monica Schwartzman: None declared, Diane Zisa: None declared, Amit Lakhanpal: None declared, Kevin Yip: None declared, Linda Yue: None declared, Juliet Aizer Grant/research support from: Pfizer and Lilly, Jessica Berman: None declared

Prioritizing Measures that Matter Within a Person-Centered Oncology Learning Health System

Background

Despite progress in developing learning health systems (LHS) and associated metrics of success, a gap remains in identifying measures to guide the implementation and assessment of the impact of an oncology LHS. Our aim was to identify a balanced set of measures to guide a person-centered oncology LHS.

Methods

A modified Delphi process and clinical value compass framework were used to prioritize measures for tracking LHS performance. A multidisciplinary group of 77 stakeholders, including people with cancer and family members, participated in 3 rounds of online voting followed by 50-minute discussions. Participants rated metrics on perceived importance to the LHS and discussed priorities.

Results

Voting was completed by 94% of participants and prioritized 22 measures within 8 domains. Patient and caregiver factors included clinical health (Eastern Cooperative Oncology Group Performance Status, survival by cancer type and stage), functional health and quality of life (Patient Reported Outcomes Measurement Information System [PROMIS] Global-10, Distress Thermometer, Modified Caregiver Strain Index), experience of care (advance care planning, collaboRATE, PROMIS Self-Efficacy Scale, access to care, experience of care, end-of-life quality measures), and cost and resource use (avoidance and delay in accessing care and medications, financial hardship, total cost of care). Contextual factors included team well-being (Well-being Index; voluntary staff turnover); learning culture (Improvement Readiness, compliance with Commission on Cancer quality of care measures); scholarly engagement and productivity (institutional commitment and support for research, academic productivity index); and diversity, equity, inclusion, and belonging (screening and follow-up for social determinants of health, inclusivity of staff and patients).

Conclusions

The person-centered LHS value compass provides a balanced set of measures that oncology practices can use to monitor and evaluate improvement across multiple domains.

Proactive infliximab optimisation using a pharmacokinetic dashboard versus standard of care in patients with Crohn's disease: study protocol for a randomised, controlled, multicentre, open-label study (the OPTIMIZE trial)

INTRODUCTION

Preliminary data indicates that proactive therapeutic drug monitoring (TDM) is associated with better outcomes compared with empiric dose escalation and/or reactive TDM, and that pharmacokinetic (PK) modelling can improve the precision of individual dosing schedules in Crohn's disease (CD). However, there are no data regarding the utility of a proactive TDM combined PK-dashboard starting early during the induction phase, when disease activity and drug clearance are greatest. The aim of this randomised, controlled, multicentre, open-label trial is to evaluate the efficacy and safety of a proactive TDM combined PK dashboard-driven infliximab dosing compared with standard of care (SOC) dosing in patients with moderately to severely active CD.

METHODS AND ANALYSIS

Eligible adolescent and adult (aged ≥16-80 years) patients with moderately to severely active CD will be randomised 1:1 to receive either infliximab monotherapy with proactive TDM using a PK dashboard (iDose, Projections Research) or SOC infliximab therapy, with or without a concomitant immunomodulator (IMM) (thiopurine or methotrexate) at the discretion of the investigator. The primary outcome of the study is the proportion of subjects with sustained corticosteroid-free clinical remission and no need for rescue therapy from week 14 throughout week 52. Rescue therapy is defined as any IFX dose escalation other than what is forecasted by iDose either done empirically or based on reactive TDM; addition of an IMM after week 2; reintroduction of corticosteroids after initial tapering; switch to another biologic or need for CD-related surgery. The secondary outcomes will include both efficacy and safety end points, such as endoscopic and biological remission, durability of response and CD-related surgery and hospitalisation.

ETHICS AND DISSEMINATION

The protocol has been approved by the Institutional Review Board Committee of the Beth Israel Deaconess Medical Center (IRB#:2021P000391). Results will be disseminated in peer-reviewed journals and presented at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT04835506.

POS0715 QUANTIFYING THE PSYCHOSOCIAL IMPACT OF UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE (UCTD)

Background:

Only half of patients diagnosed with SLE fulfill classification criteria; the rest have “SLE-like” illnesses such as UCTD. SLE patients are known to experience impaired health-related quality of life (HRQoL) and significant anxiety, depression, and fatigue,1 yet the psychosocial aspects of UCTD are less established. In a qualitative study, we found that most UCTD patients had engaged in psychotherapy and felt additional support was needed.2

Objectives:

Using multiple validated instruments, this study aims to quantify the psychosocial impact of UCTD.

Methods:

The Hospital for Special Surgery UCTD and Overlap Registry includes UCTD patients aged ≥ 18 years with ANA ≥ 1:80 and ≥ 1 sign or symptom of rheumatic disease who do not fulfill classification criteria for a defined CTD. We administered the 36-Item Short Form Health Survey (SF-36), General Anxiety Disorder-7 (GAD-7), Beck Depression Inventory (BDI), and Fatigue Severity Scale (FSS) to all patients to assess HRQoL, anxiety, depression, and fatigue. Instruments were scored based on established algorithms and results were summarized using predefined scales and severity thresholds.

Results:

The composite questionnaire was administered to 85 UCTD patients and completed by 75 (97.3% female, 60% white, mean age ± SD 48.8 ± 13.6 years). The SF-36 Physical Component Summary mean score was 37.8 and Mental Component Summary mean score was 41.1. Across the 8 SF-36 subscales, mean scores were lowest for role limitations due to physical health (39.3) and vitality (39.7) and highest for physical functioning (67.2), role limitations due to emotional health (67.1), and mental health (67.1). Approximately half of UCTD patients reported anxiety (GAD-7 ≥ 6); 20% had moderate/severe anxiety (GAD-7 ≥ 10). The prevalence of depression (BDI ≥ 14) was 26.7%; 13.3% had moderate/severe depression (BDI ≥ 20). Fatigue (FSS ≥ 3) was reported by 82.8% of patients (median FSS score of 4.7) [Table 1].

Table 1.

Psychosocial Survey Scores of Patients with Undifferentiated Connective Tissue Disease (n=75)

36-Item Short Form Health Survey (SF-36)Range 1-100 – Mean (SD)*Physical Component Summary∘Physical functioning∘Role-Physical∘Bodily PainoGeneral Health38.2 (11.2)67.2 (26.3)39.3 (46.3)49.5 (22.1)42.9 (21.5)Mental Component Summary∘Vitality∘Social Functioning∘Role-EmotionaloMental Health41.3 (10.7)39.7 (21.7)59.3 (25.9)67.1 (41.9)67.1 (18.3)Generalized Anxiety Disorder-7 (GAD-7)Range 0-21 – N (%)**None [0-5]Mild [6-10]Moderate [11-15]Severe [16-21]38 (50.7)22 (29.3)14 (18.7)1 (1.3)Beck Depression Inventory (BDI)Range 0-63 – N (%)**Minimal [0-13]Mild [14-19]Moderate [20-28]Severe [29-63]55 (73.3)10 (13.3)7 (9.3)3 (4.0)Fatigue Severity Scale (FSS) Range 1-7 – Median (IQR)**4.7 (1.5)

*Higher number indicates better health state. **Higher number indicates greater severity.

Conclusion:

UCTD patients have significantly impaired HRQoL and a high prevalence of anxiety, depression, and fatigue, suggesting substantial psychosocial impact of UCTD comparable to that reported in SLE.3,4 Impaired HRQoL in UCTD is driven to similar degrees by aspects of physical and mental health. In future studies, we will compare age- and sex- matched UCTD to SLE patients and longitudinally evaluate psychosocial metrics alongside clinical trajectories.

References:

[1]Dietz B, Katz P, Dall’Era M, et al. Major depression and adverse patient-reported outcomes in systemic lupus erythematosus: Results from a prospective longitudinal cohort. Arthritis Care Res. 2021;73(1):48-54.

[2]Siegel CH, Kleinman J, Barbhaiya M, et al. The psychosocial impact of undifferentiated connective tissue disease on patient health and well-being: A qualitative study. J Clin Rheumatol. In press.

[3]Gu M, Cheng Q, Wang X, et al. The impact of SLE on health-related quality of life assessed with SF-36: A systemic review and meta-analysis. Lupus. 2019;28(3):371-382.

[4]Zhang L, Fu T, Yin R, Zhang Q, Shen B. Prevalence of depression and anxiety in systemic lupus erythematosus: A systematic review and meta-analysis. BMC Psychiatry. 2017;17(1).

Acknowledgements:

This project was supported by the Barbara Volcker Center for Women and Rheumatic Diseases and the Robin J. Sillau Memorial Research Fund for Connective Tissue Disease. Dr. Barbhaiya is supported by the Rheumatology Research Foundation Investigator Award.

Disclosure of Interests:

None declared

Integrated Care for Crohn's Disease: A Plea for the Development of Clinical Decision Support Systems

Evolution in the management of Crohn's disease [CD] has been characterized by recent paradigm changes. First, new biological therapies induce intestinal healing and full disease control in a substantial number of patients, particularly when introduced early in the disease course. However, they are expensive and associated with potentially severe side effects, raising the question of optimal treatment duration. Secondly, progress in biomarkers and medical imaging performance has enabled better refinement of the definition and prediction of remission or relapse of the disease through monitoring [tight control]. This progress may help to improve tailoring treatment in relation to target ['treat-to target' approach], applying patient-centred and collaborative perspectives, consistent with other chronic disease management. Such an approach requires the integration of a potentially large number of parameters coming from different stakeholders. This integration would be difficult based solely on implementation of classical guidelines and the clinician's intuition. To this end, clinical decision support systems should be developed that integrate a combination of various outcomes to facilitate the treatment decision and to share information between patients, primary care specialists, and health insurance companies or health authorities. This should ease complex therapeutic decisions and serve as a basis for continued research into effectiveness of CD management.

Contributions to the theory of optimal resource allocation

A problem in optimal resource allocation is considered for n jobs with identically distributed service times admitting a monotone hazard function. If the hazard function is increasing, it is shown that the procedure of allocating the full resource individually to each job until its completion minimizes the expected completion time of the jth job. The procedure which at any instant of time equally allocated the resource among all of the remaining jobs is shown to minimize the expected total cumulative waiting time if the hazard is decreasing.

Lymphoma risk in children and young adults with inflammatory bowel disease: analysis of a large single-center cohort

BACKGROUND

Prior studies suggest an increased risk of lymphoma in adults with inflammatory bowel disease (IBD). Cases of lymphoma have also been reported in children with IBD. However, the precise risk of lymphoma in relation to drug exposure has not been ascertained in children.

METHODS

We conducted a single-center, retrospective study of 1560 children and young adults with IBD evaluated at Children's Hospital Boston between 1979 and 2008. Of this group, 186 patients were excluded due to incorrect diagnosis, one-time second-opinion visits, or missing hospital records. The remaining 1374 patients had charts reviewed to determine whether lymphoma developed while they were receiving their clinical care at our institution and the duration of exposure to various IBD medications. The rate of lymphoma was calculated in patient-years of exposure for each class of medications utilized in IBD.

RESULTS

Of 1374 patients (741 male; age at diagnosis 12.1 ± 4.0 years; 791 Crohn's disease [CD], 535 ulcerative colitis [UC], 48 IBD unclassified), we identified two patients who developed lymphoma (one Hodgkin, one anaplastic large cell), in 6624 patient-years of follow-up (mean duration follow-up 4.8 years per patient). Both patients were males (ages 12 and 18 years at time of lymphoma onset) and were receiving thiopurines but had not yet received biologics at the time of their cancer diagnosis. They were both treated with chemotherapy and are alive without cancer 32+ and 76+ months since diagnosis. The absolute incidence rate of lymphoma for patients having received thiopurines was 4.5 per 10,000 patient-years compared to the expected rate of 0.58 per 10,000 patient-years, with a standardized incidence ratio (SIR) of 7.51 (95% confidence interval [CI] 0.74-41.98).

CONCLUSIONS

The overall risk of lymphoma in children with IBD is low, with only two cases seen in our hospital over a 30-year period. The lymphoma risk (as estimated by SIR) in children receiving thiopurines is comparable to that reported in studies of adults. While there may be an increased risk of lymphoma in children treated with thiopurines, the risk did not reach statistical significance in this large cohort.

NAD+ depletion or PAR polymer formation: which plays the role of executioner in ischaemic cell death?

Multiple cell death pathways are activated in cerebral ischaemia. Much of the initial injury, especially in the core of the infarct where cerebral blood flow is severely reduced, is necrotic and secondary to severe energy failure. However, there is considerable evidence that delayed cell death continues for several days, primarily in the penumbral region. As reperfusion therapies grow in number and effectiveness, restoration of blood flow early after injury may lead to a shift towards apoptosis. It is important to elucidate what are the key mediators of apoptotic cell death after stroke, as inhibition of apoptosis may have therapeutic implications. There are two well described pathways that lead to apoptotic cell death; the caspase pathway and the more recently described caspase-independent pathway triggered by poly-ADP-ribose polymers (PARP) activation. Caspase-induced cell death is initiated by release of mitochondrial cytochrome c, formation of the cytosolic apoptosome, and activation of endonucleases leading to a multitude of small randomly cleaved DNA fragments. In contrast caspase-independent cell death is secondary to activation of apoptosis inducing factor (AIF). Mitochondrial AIF translocates to the nucleus, where it induces peripheral chromatin condensation, as well as characteristic high-molecular-weight (50 kbp) DNA fragmentation. Although caspase-independent cell death has been recognized for some time and is known to contribute to ischaemic injury, the upstream triggering events leading to activation of this pathway remain unclear. The two major theories are that ischaemia leads to nicotinamide adenine dinucleotide (NAD+) depletion and subsequent energy failure, or alternatively that cell death is directly triggered by a pro-apoptotic factor produced by activation of the DNA repair enzyme PARP. PARP activation is robust in the ischaemic brain producing variable lengths of poly-ADP-ribose (PAR) polymers as byproducts of PARP activation. PAR polymers may be directly toxic by triggering mitochondrial AIF release independently of NAD+ depletion. Recently, sex differences have been discovered that illustrate the importance of understanding these molecular pathways, especially as new therapeutics targeting apoptotic cell death are developed. Cell death in females proceeds primarily via caspase activation whereas caspase-independent mechanisms triggered by the activation of PARP predominate in the male brain. This review summarizes the current literature in an attempt to clarify the roles of NAD+ and PAR polymers in caspase-independent cell death, and discuss sex specific cell death to provide an example of the possible importance of these downstream mediators.

Significant morbidity associated with RSV infection in immunosuppressed children following liver transplantation: case report and discussion regarding need of routine prophylaxis

Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract infection in infants and young children. In immunocompromised children, RSV infection poses a serious health threat with significantly increased and prolonged virus shedding and the development of severe respiratory disease. We report two patients, eight months and 20 months of age, who were admitted with severe RSV infection two months and 10 months post-transplant respectively. Major risk factors for severe infection is the degree of immunosuppression and the age of the patient (<24 months). Based on the significant morbidity associated with RSV infection in these patients, we recommend randomized trials in larger pediatric solid organ transplant centers to evaluate the use of palivizumab prophylaxis is efficacious to prevent morbidity in patients under the age of 24 months, while we emphasize good hygienic practices to prevent RSV nosocomial infection.

Recovery from psychotic illness: a 15- and 25-year international follow-up study

BACKGROUND

Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia.

AIMS

To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables.

METHODS

Historic prospective study. Standardised assessments of course and outcome.

RESULTS

About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery.

CONCLUSIONS

A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

Statistical cost-effectiveness analysis of two treatments based on net health benefits

Statistical methods for cost-effectiveness analysis (CEA) for two treatments that mimic the deterministic optimal rules of CEA are presented. In these rules the objective is to determine the treatment with the maximal effectiveness whose unit cost is less than an amount, lambda, that a decision-maker is willing to pay (WTP). This is accomplished by identifying the treatment with the largest positive net health benefit (NHB), which is a function of lambda, while controlling the familywise error rate both when the WTP value is given and when it is unspecified. Fieller's theorem is used to determine a region of WTP values where the NHBs of the treatments are not distinguishable. For each lambda outside of the confidence region, the larger treatment is identified. A newly developed one-tailed analogue of Fieller's theorem is used to determine the WTP values where a treatment's NHB is positive. The situation in which both treatments are experimental is distinguished from the case where one of the treatments is usual care. The one-tailed confidence region is used in the latter case to obtain the lambda values where the NHBs are not different, and determining the region of positivity of the NHBs may be unnecessary. An example is presented in which the cost-effectiveness of two antipsychotic treatments is evaluated.

Efficacy of a single diagnostic test for sensitization to common inhalant allergens

BACKGROUND

UniCAP Phadiatop is a single laboratory test designed to determine the presence or absence of specific IgE to a variety of common inhalants. Its purpose is to aid in the differentiation of patients with symptoms attributable to allergic disease from other common causes.

METHODS

Consecutive children and adolescent patients (n = 145) at two centers were examined by having their history and physical examination performed by two board certified allergists. Their conclusions along with skin prick tests and specific IgE measurements regarding seven common inhalants (mite, oak, ragweed, grass, dog, cat, Alternaria) were compared with UniCAP Phadiatop test results. This was done using concordance of all test results. Attempts to resolve test discrepancies, when found, included specific RAST inhibitions, total IgE values, and physicians' judgment after testing.

RESULTS

All patients with resolved diagnoses (143 of 145, 103 positive and 40 negative) were identified correctly by the UniCAP Phadiatop test. Skin test results and specific IgE measurements correlated well, but neither correlated well with the history by itself, suggesting a minimal false-positive component of the history of 23%. UniCAP Phadiatop results demonstrated a quantitative relationship between the patient's score and the amount of IgE specific to these individual allergens.

CONCLUSIONS

The UniCAP Phadiatop test was shown to be highly sensitive and specific in differentiating individuals who are sensitized to common inhalants from those who are not. This test is recommended to all physicians as an aid in diagnostic and referral decisions for patients suspected of having an inhalant allergic diathesis.

Performance measures of cultural competency in mental health organizations

The authors utilized numerous documents created by advisory groups, expert panels and multicultural focus groups to develop performance measures for assessing the cultural competency of mental health systems. Competency was measured within three levels of organizational structure: administrative, provider network, and individual caregiver. Indicators, measures and data sources for needs assessment, information exchange, services, human resources, plans and policies, and outcomes were identified. Procedures for selection and implementation of the most critical measures are suggested. The products of this project are broadly applicable to the concerns of all cultural groups.

Novel cannabinol probes for CB1 and CB2 cannabinoid receptors

The observation that the phenolic hydroxyl of THCs was important for binding to the CB1 receptor but not as critical for binding to the CB2 receptor prompted us to extend this finding to the cannabinol (CBN) series. To study the SAR of CBN analogues, CBN derivatives with substitution at the C-1, C-3, and C-9 positions were chosen since these positions have played a key role in the SAR of THCs. CBN-3-(1',1'-dimethylheptyl) analogues were prepared by sulfur dehydrogenation of Delta(8)-THC-3-(1',1'-dimethylheptyl) analogues. 9-Substituted CBN analogues were prepared by the standard sulfur dehydrogenation of 9-substituted Delta(8)-THC analogues (Scheme 1), which in turn were prepared following our previous procedure using selenium dioxide oxidation of the corresponding Delta(8)-THCs followed by sodium chlorite oxidation to give the 9-carboxy-Delta(8)-THC derivatives. 11-Hydroxy-CBN analogues were prepared from the corresponding 9-carbomethoxy-CBN analogues by reduction with LiAlH(4). Deoxy-CBN analogue 14 was prepared from the corresponding Delta(8)-THC analogue 11 by conversion of the phenolic hydroxyl to the phosphate derivative 12, followed by lithium ammonia reduction to provide the deoxy-Delta(8)-THC analogue 13, which in turn was dehydrogenated with sulfur to provide the deoxy-CBN analogue 14 (Scheme 2). The various analogues were assayed for binding both to the brain and the peripheral cannabinoid receptors (CB1 and CB2). We have found that the binding profile differs widely between the CBN and the THC series. Specifically, in the CBN series the removal of the phenolic hydroxyl decreases binding affinity to both the CB1 and CB2 receptors, whereas in the THC series, CB1 affinity is selectively reduced. Thus, in the CBN series, the selectivity of binding observed with the removal of the hydroxy group is decreased severalfold as compared to what occurs in the THC series. Generally, high affinity for the CB2 receptor was found in analogues when the phenolic hydroxyl was present. The 3-(1', 1'-dimethylheptyl) derivatives were found to have much higher affinities than the CBN analogues, which is in complete agreement with previously reported work by Rhee et al.

Assessing the onset of relief of a treatment for migraine

It is common for clinical trials designed to compare treatments for migraine to incorporate a component for estimating onset. Our objective is to describe a stopwatch method for collecting data on time to meaningful relief and a conceptual framework for describing and analysing the results. The survival distribution of onset is modelled in two parts: the probability that onset does not occur, and the survival distribution conditional on its occurrence. Using data from a clinical trial comparing an active treatment and placebo, we illustrate the method and find that the distributions of onset among those with onset do not differ, but the probabilities that onset occurs are substantially different. We illustrate how the model can be used to help determine how long patients without onset should wait before further intervention, how patients interpret the phrase meaningful relief, and how baseline clinical characteristics affect the onset.

Talbot array illuminator for single-shot measurements of laser-induced-damage thresholds of thin-film coatings

A highly efficient Talbot array illuminator for single-shot, laser-induced-damage test measurements of optical thin-film coatings is proposed. With a periodic binary phase grating, a laser beam is transformed into an ensemble of Gaussian-like spots, which are known as the Fresnel image of the grating. For this purpose hexagonal phase gratings were fabricated and analyzed. With a peak fluence distribution of approximately 1 order of magnitude, the damage threshold of thin films can be deduced by use of the data from only a single shot.

Tenure in supportive housing for homeless persons with severe mental illness

OBJECTIVE

The study examined the long-term effectiveness of approaches to housing homeless persons with serious mental illness.

METHODS

A total of 2,937 persons placed in high-, moderate, -and low-intensity housing were followed for up to five years. Intensity reflected on the amount of structure and degree of clients' independence. The outcome variable was tenure in housing. Cox stepwise regression was used to calculate risk ratios of becoming discontinuously housed.

RESULTS

Thirty percent of the sample were initially placed in high-intensity settings, 18 percent in moderate-intensity settings, and 52 percent in low-intensity settings. Those in high-intensity settings tended to be younger, to be referred from hospitals, and to have a history or diagnosis of substance abuse. Individuals in moderate-intensity settings were more likely to be female and were least likely to have substance abuse problems. Individuals in low-intensity settings were more likely to be referred by municipal shelters and to have lived in municipal shelters for four or more months. After one, two, and five years, 75 percent, 64 percent, and 50 percent, respectively, of the sample were continuously housed. Older age was associated with longer tenure, and having a history of substance abuse was associated with shorter tenure. Individuals referred from a state psychiatric center had a greater risk of shorter tenure than other types of referrals.

CONCLUSIONS

Results show that homeless persons with serious mental illness can remain in stable housing for periods of up to five years, supporting the premise that long-term residential stability can be enhanced by providing access to safe and affordable supportive housing.

Power and sample size in cost-effectiveness analysis

For resource allocation under a constrained budget, optimal decision rules for mutually exclusive programs require that the treatment with the highest incremental cost-effectiveness ratio (ICER) below a willingness-to-pay (WTP) criterion be funded. This is equivalent to determining the treatment with the smallest net health cost. The designer of a cost-effectiveness study needs to select a sample size so that the power to reject the null hypothesis, the equality of the net health costs of two treatments, is high. A recently published formula derived under normal distribution theory overstates sample-size requirements. Using net health costs, the authors present simple methods for power analysis based on conventional normal and on nonparametric statistical theory.

Ratio-based and net benefit-based approaches to health care resource allocation: proofs of optimality and equivalence

Both incremental cost-effectiveness ratios and net benefits have been proposed as summary measures for use in cost-effectiveness analyses. We present a unifying proof of the optimality and equivalence of ICER- and net benefit-based approaches to the health resource allocation problem, including both 'fixed budget' and 'fixed price' decision rules. If internally consistent willingness-to-pay values are used, ratio- and net benefit-based decision rules identify the same optimal allocation. Because they have identical resource allocation implications, use of one or other of the two approaches must be based on other criteria, such as their behaviour under conditions of uncertainty.

Experimental determination of the fundamental-mode diameter in solid-state lasers

A method to determine directly the radius of the fundamental mode in a laser crystal has been developed. The radius is measured by comparison of the distribution of the spontaneous emission in the pumped region during laser operation with the fluorescence distribution without laser emission. Measuring the mode radius with various pump powers enables one to optimize the overlap between the pump and the cavity beam and to determine the dioptric power of the thermally induced lens.

Geographic analysis of pertussis infection in an urban area: a tool for health services planning

OBJECTIVE

This study examined whether incident cases of pertussis cluster in urban census tracts and identified community characteristics that predict high-incidence areas.

METHODS

An ecological study design was used. The study population included all persons diagnosed with pertussis from January 1, 1986, through December 31, 1994. Maps of rates were constructed via a geographic information system and clustering was statistically confirmed. Associations between pertussis rates and community characteristics were tested.

RESULTS

Mapping and statistical analysis revealed spatial clustering of pertussis. Higher age-adjusted rates of pertussis infection were associated with higher proportions of residents below poverty level.

CONCLUSIONS

In urban areas pertussis infection clusters in areas of poverty.

The cost and outcomes of community-based care for the seriously mentally ill

OBJECTIVE

To examine the cost-effectiveness of community-based mental health care.

DATA SOURCES/STUDY SETTING

Administrative data from Medicaid and the Massachusetts Department of Mental Health; primary data from 144 psychiatrically disabled adult Medicaid beneficiaries who lived in Boston, central Massachusetts, and western Massachusetts.

STUDY DESIGN

A cross-sectional observational study compared the costs and outcomes of treatment in three different types of public mental health service systems.

DATA COLLECTION/EXTRACTION METHODS

Beneficiaries, randomly sampled from outpatient mental health programs, were interviewed about their mental health status. All their acute treatment and long-term continuing care for the preceding year were abstracted from Medicaid and Department of Mental Health files. Costs were extracted from Medicaid paid claims and from Department of Mental Health contracts and other financial documents.

PRINCIPAL FINDINGS

Clients in the region allocating a greater proportion of its Department of Mental Health budget to community support services used far fewer hospital days, resulting in lower per person treatment expenditures. Outcomes, however, were not significantly different from outcomes of clients in the other regions. For all regions, substance abuse comorbidity increased hospitalization and total treatment costs. An individual-level cost-effectiveness analysis identified western Massachusetts (community-based care) as significantly more cost effective than the other two regions.

CONCLUSIONS

Systems with stronger community-based orientation are more cost effective.

The usefulness of average cost-effective ratios

We demonstrate that average cost-effectiveness ratios (CERs) play an important role in the evaluation of the cost-effectiveness of treatments. Criticisms of the usefulness of CERs derive mostly from the context of resource allocation under a constrained budget in which some decisions are based on incremental CERs. However, we show that in many cases, these decision rules are equivalent to decision rules on CERs. This follows for mutually exclusive treatments first, because a treatment is eliminated by extended dominance if and only if there is a mixed treatment with a smaller CER, where the mixing parameter lies in a certain interval. Second, after elimination of treatments by dominance and by extended dominance, resources can be allocated in order of increasing CERs. Moreover, the CER is a parameter that characterizes clinical and economical properties of a treatment independent of its comparators.

Statistical inference for cost-effectiveness ratios

Methods for statistical inference for cost-effectiveness (C/E) ratios for individual treatment and for incremental cost-effectiveness (delta C/ delta E) ratios when two treatments are compared are presented. In a lemma, we relate the relative magnitude of two C/E ratios to the delta C/ delta E ratio. We describe a statistical procedure to test for dominance, or admissibility, that can be used to eliminate an inferior treatment. The one-sided Bonferroni's confidence interval procedure is generalized to the two-sided case. The method requires only that two confidence intervals be available, one for cost and one for effectiveness. We describe Fieller-based confidence intervals and show them to be shorter than Bonferroni intervals. When distribution assumptions hold and variance and covariance estimates are available, Fieller intervals are preferable. However, Bonferroni intervals can be applied in more diverse situations and are easier to calculate. A simple Bonferroni based technique, and a likelihood ratio statistic given by Siegel, Laska and Meisner, for testing the null hypothesis that the C/E ratios of two treatments are equal is presented. The approaches are applied to the data from a phase II clinical trial of a new treatment for sepsis considered previously by others.

Biophysical characterization of cationic lipid: DNA complexes

To better understand the structures formed by the interaction of cationic lipids with DNA, we undertook a systematic analysis to determine the biophysical characteristics of cationic lipid:DNA complexes. Four model cationic lipids with different net cationic charge were found to interact in similar ways with DNA when that interaction was compared in terms of the apparent molar charge ratio of lipid to DNA. When DNA was present in charge excess over the cationic lipid, the complex carried a net negative charge as determined by zeta potential measurements. Under these conditions, some DNA was accessible to ethidium bromide, and free DNA was observed in agarose gels and in dextran density gradients. Between a lipid:DNA charge ratio of 1.25 and 1.5:1, all the DNA became complexed to cationic lipid, as evidenced by its inaccessibility to EtBr and its complete association with lipid upon agarose gel electrophoresis and density gradient separations. These complexes carried a net positive charge. The transition between negatively and positively charged complexes a occurred over a very small range of lipid to DNA ratios. Employing a fluorescent lipid probe, the addition of DNA was shown to induce lipid mixing between cationic lipid-containing vesicles. The extent of DNA-induced lipid mixing reached a maximum at a charge ratio of about 1.5:1, the point at which all the DNA was involved in a complex and the complex became positively charged. Together with freeze-fracture electron micrographs of the complexes, these biophysical data have been interpreted in light of the existing models of cationic lipid:DNA complexes.

Mental illness among homeless individuals in a suburban county

OBJECTIVE

This paper compares the prevalence of mental illnesses and alcohol and drug abuse and the residential histories of homeless individuals identified as having a mental illness and individuals who are not so identified. The cohort consisted of single persons applying for shelter over a 12-week period in Westchester County, a suburban county in New York State.

METHODS

The sample of 201 persons (89 percent male, with a mean age of 37) represented 77 percent of consecutive single shelter applicants in a single-point-of-entry system over the study period. Information from an intake assessment was augmented by a semistructured interview to reconstruct subjects' residential history for the last five years, including periods of homelessness and time in institutions.

RESULTS

Twenty-one percent of the cohort was classified as having mental illness. Seventy-two percent had a diagnosis of drug abuse or dependence, and 51 percent had alcohol abuse or dependence. For individuals with a mental illness, the use of cocaine and heroin was significantly lower, but alcohol use was somewhat greater, compared with other homeless persons. Persons with mental illness also experienced homelessness of some kind over a significantly longer period (a mean of seven years versus a mean of three years for other subjects), and they spent almost twice as many weeks during the previous five years literally homeless. Institutional time, most of which consisted of time in jail or prison, was equivalent for both groups.

CONCLUSIONS

Not only is residential instability heightened among shelter users with mental illness, but over time public institutions play a critical role in their accommodations. For some homeless persons with mental illness, the circuit of shelters, rehabilitation programs, jails, and prisons may function as a makeshift alternative to inpatient care or supportive housing and may reinforce the marginalization of this population.

Outcome in schizophrenia and related disorders compared between developing and developed countries. A recursive partitioning re-analysis of the WHO DOSMD data

BACKGROUND

Data on the two-year pattern of course of illness have been collected in the WHO study of the Determinants of Outcomes of Severe Mental Disorder (DOSMD). These data are reanalysed using recursive partitioning, a method not yet applied to psychiatric data to test the hypothesis that subjects from participating centres in developing countries had better outcomes than those in developed countries.

METHOD

Subjects were those from the DOSMD study for whom two-year follow-up data were available (n = 1056). The classification and regression trees recursive partitioning technique was used to examine the predictor variables associated with the outcome variable two year pattern of course.

RESULTS

Pattern of course was best predicted by centre, but two developed centres (Prague and Nottingham) grouped with the developing country centres excluding Cali, having better outcomes than in the remaining developed country centres and Cali. Type of onset (insidious v. non-insidious) was the next strongest predictor, but its effect differed across these two centre groupings. Effects for some groups were modified by other predictor variables, including age, child and/or adolescent problems, and gender.

CONCLUSIONS

The predominant predictor effects on two-year pattern of course continued to be centre and type of onset, but complex interactions between these variables and other predictor variables are seen in specific centre groupings not strictly defined by 'developing' and 'developed'.

Statistical methods for cost-effectiveness analyses

A statistical framework is presented for examining cost and effect data on competing interventions obtained from an RCT or from an observational study. Parameters of the join distribution of costs and effects or a regression function linking costs and effects are used to define cost-effectiveness (c-e) measures. Several new c-e measures are proposed that utilize the linkage between costs and effects on the patient level. These measures reflect perspectives that are different from those of the commonly used measures, such as the ratio of expected cost to expected effect, and they can lead to different relative rankings of the interventions. The cost-effectiveness of interventions are assessed statistically in a two stage procedure that first eliminates clearly inferior interventions. Members of the remaining admissible set are then rank ordered according to a c-e preference measure. Statistical techniques, particularly in the multivariate normal case, are given for several commonly used c-e measures. These techniques provide methods for obtaining confidence intervals, for testing the hypothesis of admissibility and for the equality of interventions, and for ranking interventions. The ideas are illustrated for a hypothetical clinical trial of antipsychotic agents for community-based persons with mental illness.