P–686 <span>safety & efficacy of the combination therapy of inositols, antioxidants and vitamins in polycystic ovarian syndrome (PCOS): A multicentric, retrospective observational study (Trazer study)</span>

Study question

Does combinations therapy of insulin sensitizing agents, antioxidants and vitamins are safe and efficacious in PCOS patients.

Summary answer

Combination therapy of inositols, antioxidants and vitamins is safe and effective non-hormonal treatment option to manage PCOS.

What is known already

Monotherapy of insulin sensitising agents, antioxidants and vitamins is beneficial in the treatment of PCOS. Nutritional supplement containing inositols, N-acetylcysteine (NAC), lycopene, chromium picolinate, vitamin D3, biotin and folic acid treatment resulted in a significant improvement in menstrual cyclicity, acne and hirsutism. But there is no evidence pertaining to the hormonal parameters and ovarian morphology. Therefore, the present investigation was planned to evaluate the effects of combination therapy of inositols, antioxidants and vitamins on sign and symptoms, metabolic and hormonal parameters in women with PCOS.

Study design, size, duration

Multicentric, retrospective, observational cohort study was planned for the first time at thirty-six fertility clinics in different states of India from April 2019 to November 2020. Both lean and obese patients (16–39 years; n = 180) with confirmed diagnosis of PCOS as per the Rotterdam/ESHRE criteria were included in study.

Participants/materials, setting, methods

Patients were received a combination therapy of insulin sensitizers, antioxidants and vitamins in a marketed formulation (Trazer F ForteTM) twice daily as a tablet for 3 months and thereafter ovulation induction was done using letrozole (2.5–5 mg). Primary outcomes were improvements in signs of PCOS (menstrual cyclicity or ovulation restoration, acne and hirsutism), body weight, body mass index, waist circumference, ovarian cysts, pregnancy rate and hormonal balance. Secondary outcome was the evaluation of side effects.

Main results and the role of chance

Combination therapy of Trazer F ForteTM containing insulin sensitising agents (inositols, NAC and chromium), antioxidants (NAC and lycopene), and vitamins (vitamin D, biotin and folic acid) showed significant improvement in menstrual cyclicity by 54.3% and 88.2% in obese PCOS cases, and 48.7% and 79.5% in lean PCOS cases after 3- and 6-month of intervention respectively. Significant improvement was observed in acne, hirsutism and ovarian cysts post-intervention in both obese and lean PCOS women. After successful completion of the treatment, significant corrections were observed in metabolic (fasting glucose, fasting insulin and HOMA-IR) and hormonal profile (free testosterone, LH:FSH ratio, AMH and progesterone) in obese as well as lean PCOS cases. The clinical pregnancy rate was 16.2% and 34.1% in obese women, and 9.9% and 22.1% in lean cases after 3- and 6-month of intervention respectively.

Limitations, reasons for caution

Prevalent of PCOS is different in different population in India with diverse ethnic background. Hence, community-based intervention studies on larger population are needed to assess the efficacy and safety of such combinations amongst different age groups of women with PCOS.

Wider implications of the findings: Since, PCOS is a multifactorial disorder, combined use of inositols, antioxidants and vitamins can be used as a promising and clinically relevant non-hormonal treatment option for the management of PCOS.

Trial registration number

NA

Dynamic changes in endoglin expression in the developing mouse heart

Endoglin (ENG) is essential for cardiovascular development and is expressed in the heart from its earliest developmental stages. ENG expression has been reported in the cardiac crescent, endocardium, valve mesenchyme and coronary vascular endothelial cells. However, its expression in these cell types is non-uniform and the dynamic changes in ENG expression during heart development have not been systematically studied. Using immunofluorescent staining we tracked ENG protein expression in mouse embryonic hearts aged from 11.5 to 17.5 days, and in postnatal and adult hearts. ENG is expressed in the endocardium and in venous endothelial cells throughout these developmental stages. ENG protein is down-regulated by approximately two-fold as a subset of early coronary veins reprogram to form arteries within the developing myocardium from E13.5. This two-fold higher ratio of ENG protein in veins versus arteries is maintained throughout cardiac development and in the adult heart. ENG is also down-regulated two-fold following mesenchymal transition of endocardial cells to form cardiac valve mesenchyme, whilst expression of the pan-endothelial marker CD31 is completely lost. A subset of epicardial cells (which do not express ENG protein) delaminate and undergo a similar mesenchymal transition to form epicardially derived cells (EPDCs). This transient intra-myocardial mesenchymal cell population expresses low levels of ENG protein, similar to valve mesenchyme. In conclusion, ENG shows dynamic changes of expression in vascular endothelial cells, endocardial cells and mesenchymal cells in the developing heart that vary according to cardiovascular cell type.

P1566 Evaluation of haptic feedback for interaction with volumetric image data in virtual reality

Funding Acknowledgements

Work supported by the NIHR i4i funded 3D Heart project [II-LA-0716-20001]

Background

3D printing is used for surgical planning of complex congenital heart disease (CHD) because it provides an intuitive 3D representation of the image data. However, the 3D print is static and it can be costly and time consuming to create. Virtual Reality (VR) is a cheaper alternative that is able to visualise volumetric images in 3D directly from the scanner, both statically (CT and MR) and dynamically (cardiac ultrasound). However, VR visualisation is not as tangible as a 3D print - this is because it lacks the haptic feedback which would make the interactions feel more natural.

Purpose

Evaluate if adding haptic feedback (vibration) to the visualisation of volume image data in VR improves measurement accuracy and user experience.

Method

We evaluated the effect of vibration haptic feedback in our VR system using a synthetic cylinder volume dataset. The cylinder was displayed in two conditions: (1) with no haptic feedback, and (2) with haptic feedback. Ten non-clinical participants volunteered in the evaluation. They were blinded to these two test conditions. The participants were asked to measure the cylinder’s diameter horizontally and vertically, and its length, in each test condition. The measurement results were compared to the ground truth to assess the measurement accuracy. Each participant also completed a questionnaire comparing their experience of the two test conditions during the experiment.

Results

The results show a marginal improvement of measurement accuracy with haptic feedback, compared to no haptics (see Figure a). However, this improvement was not statistically significant. The haptic feedback did improve the participants’ confidence about their performance and increased the ease of use in VR, hence, they preferred the haptics condition to the no haptics condition (see Figure b). Moreover, although 70% of the participants reported relying on the visual cue more than on the haptic cue, 90% found that the haptic cue was helpful for deciding where to place the measurement point. Also, 88.9% of the participants felt more immersed in the VR scene with haptic feedback.

Conclusion

Our evaluation suggests that although haptic feedback may only marginally improve measurement accuracy, participants nevertheless preferred it because it improved confidence in their performance, increased ease of use, and facilitated a more immersive user experience.

Abstract P1566 Figure.

6089Increased vascular endothelial growth factor signalling following loss of endothelial endoglin leads to peripheral arteriovenous shunting and high output heart failure

Background

Endoglin is a co-receptor for TGFbeta/BMP9/10 signalling and ENG mutations lead to the vascular disorder hereditary haemorrhagic telangiectasia type I (HHT). Endoglin is also required for normal vascular development and angiogenesis, but little is known about endoglin's role in quiescent adult vascular endothelium.

Purpose

The goal of this present study is to determine how endoglin maintains vessel calibre in adult life to prevent AVM formation and thereby protect heart function.

Methods

To investigate this role, tamoxifen was administered to adult Cdh5(PAC)-CreERT2; Engfl/fl mice to generate endothelial-specific depletion of endoglin (Eng-iKOe). Cardiac magnetic resonance imaging, myography, vascular casting, microsphere injection, immunohistology, qPCR and aortic telemetry were used to evaluate cardiovascular changes after endoglin knockdown.

Results

Endothelial-specific loss of endoglin leads to an enlarged heart and cardiomyocyte hypertrophy within 5 weeks, progressing to high output heart failure (HOHF). In vivo aortic telemetry revealed significant loss of aortic pressure within a few days of endoglin depletion. Increased cardiac size and reduced cardiac afterload were confirmed by ventricular pressure loop analysis. As HOHF could result from arteriovenous malformations (AVMs), and these are found primarily in mucocutaneous and pulmonary tissues in HHT, we systematically screened for AVMs using microspheres and vascular casting. Although AVMs were absent in the majority of tissues, they were observed in the pelvic region and may account for the rapid increase in cardiac output. The pelvic cartilaginous symphysis is a noncapsulated cartilage with a naturally high endogenous expression of vascular endothelial growth factor (VEGF). Development of pelvic AVMs in this region of high VEGF expression occurred because loss of endoglin in endothelial cells leads to increased sensitivity to VEGF and a hyper-proliferative response. Finally, we found that inhibition of VEGFR2 was protective against AVMs development, enlargement of the heart and dilatation of the ventricles.

Conclusion

Our results showed the essential role of endoglin in the maintenance of adult cardio-vasculature through crosstalk with the VEGF signalling pathway.

Acknowledgement/Funding

British Heart Foundation, Cure HHT, The Swedish Research Council, The Cardiovascular Programme at Karolinska Institutet, The Swedish Cancer Society

Strengthening African Population-Based Cancer Registration Through Regional Mentorship: UICC Fellowship Experience at Zimbabwe National Cancer Registry

Background: South Africa (SA) recently established an urban population-based cancer registry in Ekurhuleni metropolitan district in Gauteng Province. The Ekurhuleni Population-Based Cancer Registry (EPBCR) aims to inform cancer policy and comprehensive cancer control programs. The registry covers 3.5 million residents including public/private, rural/urban patients and a mix of the multiethnic SA population. The first complete year's data will be published in April 2018. It is crucial that high-quality data collected by newly established registries are comparable regionally and globally. The Union for International Cancer Control (UICC) fellowship provides a practical opportunity for South African National Cancer Registry staff to learn from the Zimbabwe National Cancer Registry (ZNCR), a well-established population-based registry in the region. Aim: To enhance the SA EPBCR through observation and application of methods for population-based cancer registration used at the ZNCR. Methods: A desktop review of published and unpublished articles/reports of the ZNCR was conducted. Semi-structured informal interviews were conducted with registry staff to understand data processes from case finding to reporting. Representative data sources were visited to understand case-finding processes. Results: The ZNCR was established in 1985 through a collaborative research agreement between the Ministry of Health (MoH) and International Agency for Research on Cancer (IARC). Its activities are overseen by a 17-member constituted multidisciplinary advisory committee. The registry staff comprise one registrar, one executive assistant (EA) and four health information assistants (HIA). The process of ensuring quality data are guided by the African Cancer Registry Network and the International Association of Cancer Registries standards for population-based cancer registries. The ZNCR uses a combination of active and passive case-finding methods where HIAs have unrestricted access to patient information in private and public sectors such as hospitals, pathology laboratories, radiotherapy centers and death registries. HIAs conduct patient interviews for accurate demographics and to complete missing information. Cases are coded according to International Classification of Diseases for Oncology-V3 and Canreg software is used for data entry, quality control and analysis. The hard copies are stored in locked cabinets in offices with restricted access. The data are then used for reporting and research. Conclusion: The support of government, commitment of advisory committee volunteers, highly trained and experienced staff are key elements behind the success of ZNCR. Strict adherence to international practices for population-based cancer registration has enabled ZNCR to produce high-quality data for research and cancer programs. The processes used by ZNCR will be customised and implemented at EPBCR.

Epidemiology, disease burden, and treatment challenges of ulcerative colitis in Africa and the Middle East

Ulcerative colitis is an idiopathic, chronic, inflammatory bowel disorder characterized by an unpredictable course of alternating cycles of relapse and remission. Traditionally viewed as a disease of Western countries, the prevalence of ulcerative colitis is reported to be increasing in the developing world. In these regions, there is the potential to further explore the etiology of the disease, mainly through genetic studies. With this in mind, we consider available data relating to the epidemiology, clinical manifestations, and disease course of ulcerative colitis in Africa and the Middle East. Current treatment approaches in these countries are also reviewed and discussed in the context of new, small molecule, orally administered therapies. Areas covered: Available data on the epidemiology, clinical manifestations, and risk factors of ulcerative colitis in Africa and the Middle East are reviewed using a PubMed database search. Expert commentary: Epidemiologic studies from African and Middle Eastern countries suggest disease trends similar to the West, and an important health and economic burden. The management of ulcerative colitis within these developing countries is challenging, with the need to improve early diagnosis, access to healthcare, and patient education, along with facilitation of access to treatment options and improvement of medication adherence.

Breast cancer trends differ by ethnicity: a report from the South African National Cancer Registry (1994-2009)

Background

To describe breast cancer (BC) incidence and mortality by ethnicity in South Africa (SA).

Methods

Sources of data included the South African National Cancer Registry (NCR) pathology-based reports (1994–2009) and Statistics South Africa (SSA) mortality data (1997–2009). Numbers of cases, age-standardised incidence rates (ASIR) and lifetime risk (LR) were extracted from the NCR database for 1994–2009. Age-specific incidence rates were calculated for five-year age categories. The direct method of standardisation was employed to calculate age-standardised mortality rates (ASMR) using mortality data.

Results

Between 1994 and 2009, there were 85 561 female BC. For the Black, Coloured and Asian groups, increases in ASIR and LR were observed between 1994 and 2009. In 2009, the ASIR for the total population, Blacks, Whites, Coloureds and Asians were 26.9, 18.7, 50.2, 40.9 and 51.2 per 100 000, respectively. For Asians, an increase in proportion of BC as a percentage of all female cancers was observed between 1994 and 2002 (11.1%) and continued to increase to 2009 (a further 4.5%). Whites and Asians presented higher incidences of BC at earlier ages compared with Blacks and Coloureds in 2009. In 1998, there were 1618 BC deaths in SA compared with 2784 deaths in 2009. ASMR between 1997 and 2004 increased but stabilised thereafter.

Conclusion

This paper demonstrated that SA BC incidence rates are similar to other countries in the region, but lower than other countries with similar health systems. Ethnic differences in BC trends were observed. However, the reasons for observed ethnic differences are unclear.

Variability of intended copies for etanercept (Enbrel®): Data on multiple batches of seven products

Fusion protein and monoclonal antibody-based tumor necrosis factor (TNF) inhibitors represent established treatment options for a range of inflammatory diseases. Regulatory authorities have outlined the structural characterization and clinical assessments necessary to establish biosimilarity of a new biotherapeutic product with the innovator biologic drug. Biologic products that would not meet the minimum World Health Organization's standard for evaluation of similar biotherapeutic products are available in some countries; in some cases relevant data to assess biosimilarity and appropriate regulatory approval pathways are lacking. Batches of seven intended copy (IC) products for etanercept (Enbrel®) were subjected to a subset of test methods used in the routine release and heightened characterization of Enbrel®, to determine key attributes of identity, quality, purity, strength, and activity. While a number of quality attributes of the IC lots tested met the release specifications for Enbrel®, none fell within these limits across all methods performed, and there were no IC lots that satisfied the criteria typically applied by the innovator to support comparability with Enbrel®. Although the consequences of these differences are largely unknown, the potential for unanticipated clinical outcomes should not be overlooked.

Circulating microRNA's as a diagnostic tool for hepatocellular carcinoma in a hyper endemic HIV setting, KwaZulu-Natal, South Africa: a case control study protocol focusing on viral etiology

Background

A wide range of studies has investigated the diagnostic proficiency of extracellular microRNAs (miRNAs) in hepatocellular cancer (HCC). HCC is expected to increase in Sub-Saharan Africa (SSA), due to endemic levels of viral infection (HBV/HIV), ageing and changing lifestyles. This unique aetiological background provides an opportunity for investigating potentially novel circulating miRNAs as biomarkers for HCC in a prospective study in South Africa.

Methods

This study will recruit HCC patients from two South African cancer hospitals, situated in Durban and Pietermaritzburg in the province of KwaZulu-Natal. These cases will include both HBV mono-infected and HBV/HIV co-infected HCC cases. The control group will consist of two (2) age and sex-matched healthy population controls per HCC case randomly selected from a Durban based laboratory. The controls will exclude patients if they have any evidence of chronic liver disease. A standardised reporting approach will be adopted to detect, quantify and normalize the level of circulating miRNAs in the blood sera of HCC cases and their controls. Reverse transcription quantitative polymerase chain reaction (RT-qPCR) will be employed to quantity extracellular miRNAs. Differences in concentration of relevant miRNA by case/control status will be assessed using the Wilcoxon rank-sum (Mann-Whitney U) test. Adjustment for multiple testing (Bonferroni correction), receiver operating curves (ROC) and optimal breakpoint analyses will be employed to identify potential thresholds for the differentiation of miRNA levels of HCC cases and their controls.

Discussion

Although there is a growing base of literature regarding the role of circulating miRNAs as biomarkers, this promising field remains a ‘work in progress’. The aetiology of HBV infection in HCC is well understood, as well as it’s role in miRNA deregulation, however, the mediating role of HIV infection is unknown. HCC incidence in SSA, including South Africa, is expected to increase significantly in the next decade. A combination of factors, therefore, offers a unique opportunity to identify candidate circulating miRNAs as potential biomarkers for HBV/HIV infected HCC.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3915-z) contains supplementary material, which is available to authorized users.

Manufacturing history of etanercept (Enbrel®): Consistency of product quality through major process revisions

Etanercept (ETN) (Enbrel®) is a soluble protein that binds to, and specifically inhibits, tumor necrosis factor (TNF), a proinflammatory cytokine. ETN is synthesized in Chinese hamster ovary cells by recombinant DNA technology as a fusion protein, with a fully human TNFRII ectodomain linked to the Fc portion of human IgG1. Successful manufacture of biologics, such as ETN, requires sophisticated process and product understanding, as well as meticulous control of operations to maintain product consistency. The objective of this evaluation was to show that the product profile of ETN drug substance (DS) has been consistent over the course of production. Multiple orthogonal biochemical analyses, which included evaluation of attributes indicative of product purity, potency, and quality, were assessed on >2,000 batches of ETN from three sites of DS manufacture, during the period 1998-2015. Based on the key quality attributes of product purity (assessed by hydrophobic interaction chromatography HPLC), binding activity (to TNF by ELISA), potency (inhibition of TNF-induced apoptosis by cell-based bioassay) and quality (N-linked oligosaccharide map), we show that the integrity of ETN DS has remained consistent over time. This consistency was maintained through three major enhancements to the initial process of manufacturing that were supported by detailed comparability assessments, and approved by the European Medicines Agency. Examination of results for all major quality attributes for ETN DS indicates a highly consistent process for over 18 years and throughout changes to the manufacturing process, without affecting safety and efficacy, as demonstrated across a wide range of clinical trials of ETN in multiple inflammatory diseases.

The management of pretibial lacerations

Introduction Pretibial lacerations are common injuries, often presenting in the elderly and infirm. Unclear management pathways often result in inappropriate care. We identify patient demographics, morbidity risk factors, injury severity and management options. Materials and methods This retrospective study involved analysing databases and hardcopy notes for patients admitted with pretibial lacerations to Addenbrooke's Hospital, January to December 2012. Microsoft Excel and Fishers exact test were used to analyse the data with a P-value of less than 0.05 representative of statistical significance. Information on patient demographics, site of lesion, preoperative symptoms, management, operative details and clinical outcomes were collected. Results A total of 36 patients were identified; the mean age was 79 years (± 16 years, 1 standard deviation) with a three to two female to male preponderance; 57% of injuries were caused by mechanical fall, 33% traumatic blunt impact and 7% road traffic accidents. American Society of Anesthesiologists physical status classification was 43% level III, 40% II, 9% I and 9% IV. Dunkin classification of severity was 33% grade III, 30% grade I, 24% grade IV and 12% grade II. Median inpatient duration was 11 days for surgically managed compared with 15 days for conservatively managed patients. Discussion Pretibial lacerations tend to affect the elderly. Management is compounded by polypharmacy and comorbidities. If inadequately managed, such injuries can adopt characteristics of chronic wounds, with lengthy inpatient stays. Surgical intervention may be appropriate where injuries are severe and the patient stable enough for theatre. Conclusions We believe that surgical management with autologous tissue repair, with minimal delay between presentation and theatre, is warranted for extensive injuries wherever possible, with conservative management used for predominantly less extensive pretibial lacerations.

Prevalence of gastrointestinal parasitism in small ruminants in western zone of Punjab, India

AIM

The aim of this study was to explore the prevalence of gastrointestinal parasitism in small ruminants in relation to various risk factors in the western zone of Punjab.

MATERIALS AND METHODS

During the study, 603 fecal samples (391 of sheep and 212 of goats) were examined qualitatively by floatation and sedimentation techniques, and quantitatively by McMaster technique.

RESULTS

Out of the 603 fecal (391 sheep and 212 goats) samples examined, 501 were found positive for endoparasitic infection with an overall prevalence of 83.08%, consisting of 85.16% and 79.24% in sheep and goats, respectively. Egg per gram in sheep was apparently more 1441.88±77.72 than goats 1168.57±78.31. The associated risk factors with the prevalence of gastrointestinal tract (GIT) parasites showed that females (85.97%) were significantly more susceptible than males (69.23%). Age wise the adults (>6 months) were significantly more prone to parasitic infection as compared to young ones (<6 months). Seasonal variation was recorded throughout the year and was significantly highest during monsoon (90.10%), followed by winter (83.84%) and summer (78.35%).

CONCLUSION

The study revealed an overall prevalence of 83.08% of GIT parasitic infections in small ruminants constituting 85.16% in sheep and 79.24% in goats in the western zone of Punjab. The most relevant risk factors for the prevalence of gastrointestinal parasitism in ruminants were sex, age, and season.

The prevalence and clinical characteristics of nonradiographic axial spondyloarthritis among patients with inflammatory back pain in rheumatology practices: a multinational, multicenter study

BACKGROUND

Patients with ankylosing spondylitis (AS), who by definition have radiographic sacroiliitis, typically experience symptoms for a decade or more before being diagnosed. Yet, even patients without radiographic sacroiliitis (i.e., nonradiographic axial spondyloarthritis [nr-axSpA]) report a significant disease burden. The primary objective of this study was to estimate the prevalence and clinical characteristics of nr-axSpA among patients with inflammatory back pain (IBP) in rheumatology clinics in a number of countries across the world. A secondary objective was to estimate the prevalence of IBP among patients with chronic low back pain (CLBP).

METHODS

Data were collected from 51 rheumatology outpatient clinics in 19 countries in Latin America, Africa, Europe, and Asia. As consecutive patients with CLBP (N = 2517) were seen by physicians at the sites, their clinical histories were evaluated to determine whether they met the new Assessment of SpondyloArthritis international Society criteria for IBP. For those who did, their available clinical history (e.g., family history, C-reactive protein [CRP] levels) was documented in a case report form to establish whether they met criteria for nr-axSpA, AS, or other IBP. Patients diagnosed with nr-axSpA or AS completed patient-reported outcome measures to assess disease activity and functional limitations.

RESULTS

A total of 2517 patients with CLBP were identified across all sites. Of these, 974 (38.70 %) fulfilled the criteria for IBP. Among IBP patients, 29.10 % met criteria for nr-axSpA, and 53.72 % met criteria for AS. The prevalence of nr-axSpA varied significantly by region (p < 0.05), with the highest prevalence reported in Asia (36.46 %) and the lowest reported in Africa (16.02 %). Patients with nr-axSpA reported mean ± SD Ankylosing Spondylitis Disease Activity Scores based on erythrocyte sedimentation rate and CRP of 2.62 ± 1.17 and 2.52 ± 1.21, respectively, indicating high levels of disease activity (patients with AS reported corresponding scores of 2.97 ± 1.13 and 2.93 ± 1.18). Similarly, the overall Bath Ankylosing Spondylitis Disease Activity Index score of 4.03 ± 2.23 for patients with nr-axSpA (4.56 ± 2.17 for patients with AS) suggested suboptimal disease control.

CONCLUSIONS

These results suggest that, in the centers that participated in the study, 29 % of patients with IBP met the criteria for nr-axSpA and 39 % of patients with CLBP had IBP. The disease burden in nr-axSpA is substantial and similar to that of AS, with both groups of patients experiencing inadequate disease control. These findings suggest the need for early detection of nr-axSpA and initiation of available treatment options to slow disease progression and improve patient well-being.

Clinical and regulatory perspectives on biosimilar therapies and intended copies of biologics in rheumatology

Biologics are vital to the management of patients with rheumatic and musculoskeletal diseases such as rheumatoid arthritis and other inflammatory and autoimmune conditions. Nevertheless, access to these highly effective treatments remains an unmet medical need for many people around the world. As patents expire for existing licensed biologic (originator) products, biosimilar products can be approved by regulatory authorities and enter clinical use. Biosimilars are highly similar copies of originator biologics approved through defined and stringent regulatory processes after having undergone rigorous analytical, non-clinical, and clinical evaluations. The introduction of high-quality, safe, and effective biosimilars has the potential to expand access to these important medicines. Biosimilars are proven to be similar to the originator biologic in terms of safety and efficacy and to have no clinically meaningful differences. In contrast, “intended copies” are copies of originator biologics that have not undergone rigorous comparative evaluations according to the World Health Organization recommendations, but are being commercialized in some countries. There is a lack of information about the efficacy and safety of intended copies compared with the originator. Furthermore, they may have clinically significant differences in formulation, dosages, efficacy, or safety. In this review, we explore the differences between biosimilars and intended copies and describe key concepts related to biosimilars. Familiarity with these topics may facilitate decision making about the appropriate use of biosimilars for patients with rheumatic and musculoskeletal diseases.

Patient attitudes and understanding about biosimilars: an international cross-sectional survey

OBJECTIVE

To understand the levels of awareness, usage, and knowledge of biosimilars among patients, caregivers, and the general population in the US and the European Union; perceptions of biosimilars compared to originator biologics; perceived benefits and drawbacks of clinical trials; and whether advocacy groups impact patients' willingness to try a biosimilar.

METHODS

An international survey was conducted which contained up to 56 closed-ended (requiring yes/no or ranking answers) and open-ended questions, depending on the population assigned. The survey was divided into distinct sections, including medication-class awareness, usage, and knowledge about biologic and biosimilar therapies; perceptions of clinical trials; and involvement in advocacy groups. Interviews were conducted in adults categorized as: 1) diagnosed: patients with inflammatory bowel disease including Crohn's disease and ulcerative colitis, rheumatoid arthritis, psoriasis, breast cancer, lung cancer, colorectal cancer, or non-Hodgkin's lymphoma; 2) diagnosed advocacy: individuals with these diseases who participated in patient support groups; 3) caregiver: has a loved one with these conditions and is involved in medical decisions; 4) general population: aged 18-64 years, without these conditions. Statistical analyses among groups within a region (US or EU) used column proportions test with a 95% confidence interval.

RESULTS

In all, 3,198 individuals responded. Awareness about biologic therapies was significantly higher in diagnosed, diagnosed advocacy, and caregiver groups (45%-78%) versus general population (27%; P<0.05). Across all groups, awareness of biosimilars was low; only 6% of the general population reported at least a general impression of biosimilars. Awareness was significantly higher in the diagnosed advocacy group (20%-30%; P<0.05). Gaps in knowledge about biosimilars included safety, efficacy, and access to these agents. Respondents had generally positive perceptions of clinical trials, although barriers to participation were identified.

CONCLUSION

An immediate need exists for patient education about biosimilars and clinical trials to ensure educated and informed decisions are made about biosimilar use.

Effects of elevated ozone on photosynthesis and stomatal conductance of two soybean varieties: a case study to assess impacts of one component of predicted global climate change

Global climatic change scenarios predict a significant increase in future tropospheric ozone (O(3)) concentrations. The present investigation was done to assess the effects of elevated O(3) (70 and 100 ppb) on electron transport, carbon fixation, stomatal conductance and pigment concentrations in two tropical soybean (Glycine max L.) varieties, PK 472 and Bragg. Plants were exposed to O(3) for 4 h.day(-1) from 10:00 to 14:00 from germination to maturity. Photosynthesis of both varieties were adversely affected, but the reduction was higher in PK 472 than Bragg. A comparison of chlorophyll a fluorescence kinetics with carbon fixation suggested greater sensitivity of dark reactions than light reactions of photosynthesis to O(3) stress. The O(3)-induced uncoupling between photosynthesis and stomatal conductance in PK 472 suggests the reduction in photosynthesis may be attributed to a factor other than reduced stomatal conductance. An increase in internal CO(2) concentration in both O(3)-treated soybean varieties compared suggests that the reduction in photosynthesis was due to damage to the photosynthetic apparatus, leading to accumulation of internal CO(2) and stomatal closure. The adverse impact of O(3) stress increased at higher O(3) concentrations in both soybean varieties leading to large reductions in photosynthesis. This study suggests that O(3)-induced reductions in photosynthesis in tropical and temperate varieties are similar.

Conservative management of delayed suprapubic abscess after laparoscopic Burch colposuspension using nonabsorbable polypropylene mesh

To our knowledge, abscess formation after laparoscopic Burch colposuspension using permanent surgical mesh has not been previously reported. In our patient a suprapubic abscess was identified 4 weeks after the procedure in which polypropylene mesh was used. Conservative management involving drainage under computerized tomographic guidance and antibiotic therapy resulted in complete resolution without necessitating removal of the mesh. (J Am Assoc Gynecol Laparosc 6(2):225-228, 1999)

Some new N-substituted alpha-aryl/alkyl succinimides as possible anticonvulsants

In view of their expected MAO inhibitory CNS depressant and anticonvulsant properties a number of N-(5-alkyl-1,3,4-thiadiazol-2-yl)-alpha-aryl/alkyl succinimides (1-20) and N-(cyclohexyl)-alpha-aryl/alkyl succinimides (21-25) have been synthesized. Some of them when screened for anticonvulsant activity against pentetrazole induced seizures in mice at a dose of 80 mg/kg were found to be 10 to 50% active.

Variability in limb malformations and possible significance in the pathogenesis of an inherited congenital neuromuscular disease of Charolais cattle (syndrome of arthrogryposis and palatoschisis)

Limb abnormalities in 30 calves with an inherited congenital neuromuscular disorder known as syndrome of arthrogryposis and palatoschisis were classified according to the range of severity of joint deformity in either flexion or extension, and restricted joint movement. Joint movement was variably affected; it was either normal, lax, restricted in the range of mobility, or occasionally, fixed. The characteristic findings were: bilateral hyperextension of the hind fetlock, flexion deformity of the forelimb that particularly involved the fetlock and the carpus, with restricted articular movement and complete rigidity in some cases. One-third of calves also had medial deviation of the forelimb due to angular deformity of articular surfaces in the carpus. All nine live calves were floppy due to marked generalized muscular hypotonia. Birth weight of deformed calves was reduced. In some calves muscle development was impaired as judged by muscle weight, and histological examination. In some calves the gross appearance, muscle weight and histological examination revealed no abnormal development and indicated that the effects on skeletal muscle were secondary. No lesions were found in the spinal cord of 23 of 24 calves examined histologically. The remaining calf had a localized cavitation in the dorsal white matter at T2-3. Based on the observations in calves in this study it is proposed that both primary and secondary factors contribute to the phenotypic expression of this congenital deformity. The primary lesion is considered to be a neurogenic abnormality of differentiation in the central nervous system. Cytogenetic analysis of 16 carrier cows and two deformed calves showed normal karyotypes. Serology for Akabane virus in 16 carrier cows was negative.

Neurotoxic effects of endogenous materials: quinolinic acid, L-pyroglutamic acid, and thyroid releasing hormone (TRH)

The previously reported, dose-related, and selective neurotoxic action of 100 to 200 nmol quinolinic acid on intrastriatal injection was confirmed. A slight neurotoxicity was obtained with 250 nmol thyroid releasing hormone but not with a similar dose of L-pyroglutamic acid.

Disablement and helping

This study investigated the effect of apparent disablement and sex differences on helping behaviour. Women received more help than men but the presence of a wheelchair did not decrease the amount of help offered. It is suggested that the presence of a wheelchair may cause less embarrassment to the help-giver than other more disfiguring handicaps.

Some new 2-aryloxymethyl-3-alpha-substituted carboxymethyl-6,8-substituted-4-quinazolones as possible anticonvulsants

In view of their expected MAO inhibitory, CNS depressant and anticonvulsant properties, thirty new 2-aryloxymethyl-3-alpha-substituted carboxymethyl-6,8-substituted-4-quinazolones were synthesized by the reaction of substituted anthranil with various amino acids in pyridine. Some of these compounds at a concentration of 1 X 10(-3) mol/l inhibited rat brain monamine oxidase (MAO) in vitro and provided protection against pentylenetetrazole induced convulsions in mice.