Retrospective chart review of transplant recipients with cytomegalovirus infection who received maribavir in the Phase 3 SOLSTICE trial: Data at 52 weeks post-maribavir treatment initiation

BACKGROUND

Cytomegalovirus (CMV) infection is a frequent complication in haematopoietic cell/solid organ transplant (HCT/SOT) recipients. Previous studies report all-cause mortality rates of 31% and 50% in HCT/SOT recipients post-treatment initiation with conventional anti-CMV therapies for refractory or resistant CMV.

METHODS

This was a multi-country, retrospective medical chart review study of HCT/SOT recipients with refractory CMV infection with or without resistance (R/R) who were randomized to the maribavir arm in the open-label Phase 3 SOLSTICE trial. Patients came from 21 SOLSTICE sites across 6 countries; each site randomized ≥3 patients to the maribavir arm. Patients were followed for 52 weeks (SOLSTICE trial period: 20 weeks; follow-up chart review period: 32 weeks). The primary outcomes were mortality and graft status.

RESULTS

Of 234 patients who were randomized and received maribavir in SOLSTICE, chart abstraction was completed for all 109 patients enrolled across 21 trial sites (SOT, 68/142; HCT, 41/92). At 52 weeks, overall mortality was 15.6% (17/109) and survival probability was 0.84. Among SOT recipients, survival probability was 0.96, and 3 (4.4%) deaths occurred during the chart review period. For the HCT recipients, survival probability was 0.65 with 14 (34.1%) deaths; 8 occurred during SOLSTICE and 6 during the chart review period. No new graft loss or re-transplantation occurred during the chart review period.

CONCLUSIONS

Overall mortality at 52 weeks post-maribavir treatment initiation in this sub-cohort of patients from the SOLSTICE trial was lower than that previously reported for similar populations treated with conventional therapies for R/R cytomegalovirus infection.

Vedolizumab and Anti-Tumour Necrosis Factor α Real-World Outcomes in Biologic-Naïve Inflammatory Bowel Disease Patients: Results from the EVOLVE Study

BACKGROUND AND AIMS

This study aimed to compare real-world clinical effectiveness and safety of vedolizumab, an α4β7-integrin inhibitor, and anti-tumour necrosis factor-α [anti-TNFα] agents in biologic-naïve ulcerative colitis [UC] and Crohn's disease [CD] patients.

METHODS

This was a 24-month retrospective medical chart study in adult UC and CD patients treated with vedolizumab or anti-TNFα in Canada, Greece and the USA. Inverse probability weighting was used to account for differences between groups. Primary outcomes were cumulative rates of clinical effectiveness [clinical response, clinical remission, mucosal healing] and incidence rates of serious adverse events [SAEs] and serious infections [SIs]. Secondary outcomes included cumulative rates of treatment persistence [patients who did not discontinue index treatment during follow-up] and dose escalation and incidence rates of disease exacerbations and disease-related surgeries. Adjusted analyses were performed using inverse probability weighting.

RESULTS

A total of 1095 patients [604 UC, 491 CD] were included. By 24 months, rates of clinical effectiveness were similar between groups, but incidence rates of SAEs (hazard ratio [HR] = 0.42 [0.28-0.62]) and SIs (HR = 0.40 [0.19-0.85]) were significantly lower in vedolizumab vs anti-TNFα patients. Rates of treatment persistence [p < 0.01] by 24 months were higher in vedolizumab patients with UC. Incidence rates of disease exacerbations were lower in vedolizumab patients with UC (HR = 0.58 [0.45-0.76]). Other outcomes did not significantly differ between groups.

CONCLUSION

In this real-world setting, first-line biologic therapy in biologic-naïve patients with UC and CD demonstrated that vedolizumab and anti-TNFα treatments were equally effective at controlling disease symptoms, but vedolizumab has a more favourable safety profile.

Physical and occupational therapy referral and use among systemic sclerosis patients with impaired hand function: results from a Canadian national survey

OBJECTIVES

Contractures and deformities of the hand are major factors in disability and reduced health-related quality of life in systemic sclerosis (SSc). Physical (PT) and occupational therapy (OT) have been emphasised to address impaired hand function, but little is known about the extent they are employed. The objective of this study was to determine the proportion of Canadian SSc patients with hand involvement who are referred to and use PT or OT services and factors associated with referral.

METHODS

Participants were respondents to the Canadian Scleroderma Patient Survey of Health Concerns and Research Priorities who rated ≥1 of 5 hand problems (hand stiffness, difficulty making fist, difficulty holding objects, difficulty opening hand, difficulty with faucet) as occurring at least sometimes with moderate or higher impact. Patients indicated if their physicians recommended PT or OT and if they used these services. Multivariate logistic regression assessed independent predictors of PT or OT referral.

RESULTS

Of 317 patients with hand involvement, 90 (28%) reported PT or OT referral, but only 39 (12%) reported using these services. PT or OT referral was associated with more hand problems (odds ratio [OR]=1.24, 95% confidence interval [CI] 1.02-1.51, p=0.031) younger age (OR=0.96, 95% CI 0.94-0.99, p=0.004) and not being employed (OR=0.50, 95% CI 0.26-0.97, p=.0041).

CONCLUSIONS

Few SSc patients with hand involvement are referred to PT or OT, and even fewer use these services. High-quality randomised controlled trials of PT and OT interventions to improve hand function in SSc are needed.

New directions for patient-centred care in scleroderma: the Scleroderma Patient-centred Intervention Network (SPIN)

Systemic sclerosis (SSc), or scleroderma, is a chronic multisystem autoimmune disorder characterised by thickening and fibrosis of the skin and by the involvement of internal organs such as the lungs, kidneys, gastrointestinal tract, and heart. Because there is no cure, feasibly-implemented and easily accessible evidence-based interventions to improve health-related quality of life (HRQoL) are needed. Due to a lack of evidence, however, specific recommendations have not been made regarding non-pharmacological interventions (e.g. behavioural/psychological, educational, physical/occupational therapy) to improve HRQoL in SSc. The Scleroderma Patient-centred Intervention Network (SPIN) was recently organised to address this gap. SPIN is comprised of patient representatives, clinicians, and researchers from Canada, the USA, and Europe. The goal of SPIN, as described in this article, is to develop, test, and disseminate a set of accessible interventions designed to complement standard care in order to improve HRQoL outcomes in SSc.

Is there room for criticism of studies of psychodynamic psychotherapy?

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler declared unequivocally that "empirical evidence supports the efficacy of psychodynamic therapy" (p. 98). He did not mention any specific criticisms that have been made of evidence on psychodynamic psychotherapies or address possible distinctions between evidence for short-term versus long-term psychodynamic psychotherapies. Instead, he attributed dissenting views to biases in evidence dissemination and review, which he suggested are rooted in a "lingering distaste in the mental health professions professions for past psychoanalytic arrogance and authority" related to a "hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research" (Shedler, 2010, p. 98). Shedler (2010) justified his blanket dismissal of criticisms of evidence supporting psychodynamic psychotherapy on the basis of several published meta-analyses. The validity of conclusions from metaanalyses depends on the quality of the evidence synthesized, the nature of the studies included, and the rigor of the statistical analyses employed. Many meta-analyses, however, are not performed rigorously, which can result in treatment efficacy estimates that obscure important intertrial differences and that are unlikely to be replicated in clinical practice.

Frequency and impact of symptoms experienced by patients with systemic sclerosis: results from a Canadian National Survey

OBJECTIVE

Knowledge about the range of symptoms experienced by patients with SSc, and their impact on daily functioning is limited. The objective of the present study was to identify symptoms of SSc that patients rated as frequent and that highly impacted their ability to carry out daily activities.

METHODS

A total of 464 persons with SSc responded to the Canadian Scleroderma Patient Survey of Health Concerns and Research Priorities, including questions regarding the frequency and impact of 69 SSc symptoms. Descriptive analyses were performed dichotomizing symptom frequencies as never or rarely vs sometimes, most of the time or always and symptom impact on daily activities as no or minimal impact vs moderate to severe impact.

RESULTS

The five highest rated symptoms in terms of frequency and moderate to severe impact on daily activities, respectively, were: fatigue (89 and 72%), RP (86 and 67%), hand stiffness (81 and 59%), joint pain (81 and 64%) and difficulty sleeping (76 and 59%). In addition to these symptoms, items related to decreased hand function (difficulty making a fist and difficulty holding objects) and pain (muscle pain and joint tenderness) were frequently endorsed and commonly associated with moderate to severe impact on daily activities.

CONCLUSION

This study confirmed the importance for quality of life of core symptoms of SSc, such as pain, fatigue and limitations in hand function. It also identified areas with very little research, such as sleep problems, that appear to play important roles in daily functioning, and that merit more focused study.

Is longer-term psychodynamic psychotherapy more effective than shorter-term therapies? Review and critique of the evidence

BACKGROUND

In 2008, Leichsenring and Rabung performed a meta-analysis of 8 studies of longer-term psychodynamic psychotherapy (LTPP). The work was published in the Journal of the American Medical Association (vol. 300, pp 1551-1565), and they concluded that LTPP was more effective than shorter-term therapies.

METHOD

Given that such claims have the potential to influence treatment decisions and policies, we re-examined the meta-analysis and the 8 studies.

RESULTS

We found a miscalculation of the effect sizes used to make key comparisons. Claims for the effectiveness of LTPP depended on a set of small, underpowered studies that were highly heterogeneous in terms of patients treated, interventions, comparison-control groups, and outcomes. LTPP was compared to 12 types of comparison-controls, including control groups that did not involve any psychotherapy, short-term psychodynamic psychotherapy, and unvalidated treatments. Additionally, the studies failed to protect against threats to bias, and had poor internal validity.

CONCLUSION

Overall, we found no evidence to support claims of superiority of LTPP over shorter-term methods of psychotherapy.

A systematic comparison of fatigue levels in systemic sclerosis with general population, cancer and rheumatic disease samples

OBJECTIVES

There are no studies of fatigue levels in patients with SSc. The objective of this study was to compare fatigue in SSc to general population samples and patients with rheumatic diseases and cancer, where fatigue has been researched extensively.

METHODS

SSc patients completed the General Fatigue Index (GFI) of the Multidimensional Fatigue Inventory. A systematic review was conducted to select comparison samples. Mean GFI scores from SSc patients were compared with mean scores from comparison samples with t-tests and Bonferroni corrections (family-wise P < 0.05).

RESULTS

A total of 106 SSc patients were sampled (97 females; 28 diffuse SSc; 11.9 +/- 7.9 yrs since diagnosis). Based on comparisons from the systematic review, mean GFI scores in SSc (13.3 +/- 4.6) were significantly higher (greater fatigue; P < 0.05) than in two large population samples (8.7 and 9.6) and than in two samples of cancer patients in remission (9.4 and 10.0). Scores for the SSc sample were significantly lower (less fatigue) compared with two samples of cancer patients in palliative care (16.8 and 17.0). SSc GFI scores were similar to scores from patients with RA (13.4), AS (13.0) and SLE (13.1) and to scores from six studies of cancer patients in active treatment (11.1-13.5).

CONCLUSIONS

The high levels of fatigue reported in SSc were similar to patients with varying types and treatment stages of cancer and patients with other rheumatic diseases when assessed with the GFI, demonstrating that fatigue warrants greater attention in SSc.

Influence of free fatty acids and glucose infusion on serum bilirubin and bilirubin binding to albumin: clinical implications

We studied the risk of a large group of jaundiced neonates for bilirubin encephalopathy by serial assessment of their reserve serum albumin binding capacity as measured by the saturation index test. In 1271 infants with serum bilirubin concentration greater than 10 mg/dl, 12% had a saturation index (SI) of 7% or greater and therefore were clinically at or near risk for bilirubin encephalopathy. Treatment with glucose infusion (1 gm/kg over one hour) was highly effective in lowering the SI (delta = -3.7%. P less than 0.001). In none of the infants did SI rebound to 7% or greater within 24 hours after the infusion. In a detailed study of 19 infants who received glucose, the highly significant (P less than 0.001) fall in SI (delta = -3.7%) was accompanied by an equally significant rise in serum values for insulin (delta = +21.6 mcu/ml) and fall in serum free fatty acids (delta = -0.51 mEq/L). Many factors in the study, such as prematurity, hemolysis, acidosis, and hypoxemia, could have predisposed the infants to the risk of bilirubin encephalopathy. However, the facility by which most (93%) of the infants with high SI, including those who were premature or had evidence of hemolysis or respiratory insufficiency, responded to infusion of glucose indicates that serum free fatty acids may be the principal factor contributing to the high saturation index and therefore an underestimated factor in bilirubin binding to albumin.